March 29, 2025
3 min learn
Key takeaways:
- Acute left ventricular thrombus happens in about 3% of all sufferers with STEMI.
- Rivaroxaban demonstrated related efficacy and security to warfarin for decision of left ventricular thrombus after coronary heart assault.
CHICAGO — Within the RIVAWAR trial, sufferers hospitalized for a coronary heart assault who had been handled with rivaroxaban for left ventricular thrombus had comparable outcomes at 3 months to sufferers handled with warfarin.
At 3 months of follow-up, efficacy and security of rivaroxaban was much like warfarin for decision of left ventricular thrombus (LVT). Furthermore, there have been no extra deaths, strokes or main bleeds.
Acute left ventricular thrombus happens in about 3% of all sufferers with STEMI. Picture: Adobe Inventory
“These findings assist rivaroxaban as a viable various to warfarin, providing predictable dosing and eliminating the necessity for routine INR monitoring in sufferers with post-MI left ventricular thrombus,” Jehangir Ali Shah, MBBS, affiliate professor on the Nationwide Institute of Cardiovascular Illnesses (NICVD) in Karachi, Pakistan, mentioned throughout a press convention on the American Faculty of Cardiology Scientific Session.
Acute LVT, which is related to danger for embolic occasions and dying, happens in about 3% of all sufferers with STEMI and 9% of sufferers with anterior STEMI, in keeping with Shah. The really helpful first-line remedy is warfarin, however it requires frequent blood assessments and it interacts with many meals and different medicines. Direct oral anticoagulants have benefits over warfarin and are more and more utilized in sufferers with acute LVT, Shah mentioned right here.
RIVAWAR was an open-label, randomized managed trial designed to judge efficacy and security of rivaroxaban in contrast with warfarin for sufferers with acute LVT after MI. The examine was carried out on the NICVD.
The researchers randomly assigned 261 sufferers to rivaroxaban or warfarin for 3 months. The intervention interval included 1 month of twin antiplatelet remedy adopted by single antiplatelet remedy for 8 weeks together with the oral anticoagulant. Guideline-directed medical remedy for LV dysfunction was additionally began. Echocardiography was carried out at 1 month and once more at 3 months, Shah mentioned through the press convention.
Greater than three-quarters of sufferers (79.3%) had been males and the imply age was 54.5 years. Ninety % of sufferers had a STEMI, and PCI was carried out in 85%. About 94% had LV ejection fraction of 35% or much less.
At 1 month, LVT decision occurred in 20.1% of sufferers assigned rivaroxaban in contrast with 8.3% assigned warfarin (OR = 2.41; 95% CI, 1.05-2.46; P = .017), in keeping with outcomes introduced right here. At 3 months, the clot decision price was 95.8% within the rivaroxaban group in contrast with 96.6% within the warfarin group (OR = 0.98; 95% CI, 0.74-1.29; P = .88), Shah mentioned.
Jehangir Ali Shah
“In sufferers with post-MI LVT, rivaroxaban demonstrated related efficacy to warfarin in decision of LVT at 3 months’ follow-up, with full decision of greater than 95% of sufferers in each teams,” Shah mentioned.
As well as, Shah mentioned, “there was no proof of extra hurt by way of mortality, stroke or bleeding.”
All-cause mortality was related at 3.5% within the rivaroxaban group vs. 3.3% within the warfarin group (P > .999), ischemic stroke in 3.5% vs. 1.1% (P = .428) and main bleeding in 2.3% vs. 1.1% (P = .662).
Throughout a dialogue of the outcomes, Anna E. Bortnick, MD, PhD, MSc, FACC, affiliate director of structural and valvular coronary heart illness at Montefiore Einstein and chair-elect of the ACC Interventional Council, mentioned the RIVAWAR trial solutions the “burning query” of the best way to handle sufferers with LVT after MI.
“What we haven’t had till now’s a solution about whether or not or not we will use the direct oral anticoagulants and be assured that we’re going to get an excellent consequence for the affected person — if that little clot goes to dissolve — in addition to if we had been utilizing the gold customary, which is warfarin. Warfarin is tougher for sufferers and physicians to make use of, as in comparison with rivaroxaban, which is sort of a ‘pop-and-go’ technique. Now we have now a bit extra proof to assist the thought of utilizing rivaroxaban.
“What [was demonstrated] right here is … an excellent consequence at 1 month, by way of dissolving the clot. And we see with warfarin, it’s OK out to three months — that’s effective, we will use both technique — however we will be assured about utilizing that pop-and-go technique with the direct oral anticoagulant rivaroxaban,” Bortnick mentioned.
There are a number of limitations of the RIVAWAR trial, together with its single-center and open-label design. Comply with-up additionally ended after 3 months attributable to a scarcity of funding, in keeping with data in an ACC press launch.
Reference:
Perspective
This was a really attention-grabbing and thrilling examine. LVT is a significant downside after MI, particularly anterior STEMI. Though it’s not frequent, it is vitally troublesome to handle and deal with some sufferers, as a result of you must give them anticoagulation.
Up till now, the information have been combined on how profitable anticoagulation is on this inhabitants, and whether or not or not a direct oral anticoagulant can be as profitable as warfarin. RIVAWAR was a well-designed examine evaluating rivaroxaban, a DOAC, with warfarin for sufferers with LVT after MI. It’s exhausting to do a examine on this house, so kudos to the authors for taking it on. One key takeaway is that anticoagulation is efficient. Greater than 95% of sufferers had decision of their LV thrombus inside 12 weeks, which is reassuring. One other is that rivaroxaban was simply as efficient as warfarin, which I used to be stunned about. In research in atrial fibrillation and different areas, there may be some suggestion that no less than in the case of remedy of thrombotic occasions, the DOAC is perhaps at a slight drawback to warfarin. So it’s reassuring that right here, it was as efficient as warfarin. And rivaroxaban has a greater security profile, will be taken as soon as per day and doesn’t require monitoring based mostly on worldwide normalized ratio. From a affected person perspective, it is a huge win.
This real-world, pragmatic examine has direct medical implications. DOACs are as protected and efficient as warfarin and are extra handy. That’s helpful data in and of itself.
I had been of the mindset that in case you had LVT, you ought to be anticoagulated with warfarin. However now, I really feel higher about giving a DOAC, as a result of that is the one randomized managed trial on this house. This might change observe.
Grant Reed, MD, MSc, FACC, FSCAI
Interventional Heart specialist
Program Director, Interventional Cardiology Fellowship
Robert and Suzanne Tomsich Division of Cardiovascular Drugs
Sydell and Arnold Miller Household Coronary heart, Vascular & Thoracic Institute
Cleveland Clinic
Disclosures: Reed experiences no related monetary disclosures.
Sources/Disclosures
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Shah J, et al. Late-breaking medical trials II. Offered at: American Faculty of Cardiology Scientific Session; March 29-31, 2025; Chicago (hybrid assembly).
Disclosures:
Bortnick is chair-elect of the ACC Interventional Council; she experiences receiving advisor charges/honoraria from Getinge and Zoll, unrestricted academic grant(s) to her establishment from Zoll and analysis/analysis grants from Amgen. Shah experiences no related monetary disclosures.
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