An Updated Meta-Analysis of Randomized Controlled Trials Comparing Direct Oral Anticoagulants Against Warfarin for Left Ventricular Thrombus Resolution
Abstract
1. Introduction
2. Materials and Methods
2.1. Eligibility Criteria
2.2. Search Strategy
2.3. Study Selection
2.4. Data Extraction and Quality Assessment
Study | Total Number of Patients and Country | RCT Type and Intervention | Inclusion and Exclusion Criteria | Follow-Up Duration | Endpoints |
---|---|---|---|---|---|
Isa et al. 2020 [17] | n = 27 Malaysia | Pilot, prospective, single-center, randomized, single-blinded outcome study Apixaban 5 mg BD or 2.5 mg BD for 12 weeks, based on recommendation Warfarin with initial heparin infusion, aiming for a target INR of 2–3 | Inclusion criteria:
Exclusion criteria:
| 15 weeks (Echocardiography 12 weeks) | Primary outcome: 12 weeks percentage of LVT mean size reduction or total resolution Secondary outcomes: All-cause mortality Ischemic stroke Worsening heart failure |
Abdelnabi et al. 2021 [19] | n = 79 Egypt Bulgaria | Prospective, open-label, multi- center, RCT Rivaroxaban 20 mg daily Warfarin with initial enoxaparin until reaching target INR 2–3 | Inclusion criteria
Exclusion criteria
| 1, 3, 6 months | Primary outcomes: Presence or absence of LVT as assessed by 2D transthoracic echocardiography Secondary outcomes: Stroke or systemic embolism Major bleeding |
Alcalai et al. 2022 [18] | n = 35 Israel | Multicentre, national, randomized open-label non-inferiority clinical trial Apixaban 5 mg BD or 2.5 mg BD for 3 months dose based on recommendations Warfarin targeting INR 2–3 | Inclusion criteria:
Exclusion criteria:
| 3 months | Primary outcome: Presence and dimensions of LVT as assessed by 2D echocardiography Secondary outcomes: Stroke or systemic embolism Major bleeding All-cause mortality |
Youssef et al. 2023 [15] | n = 50 Saudi Arabia | Open-label RCT Apixaban 5 mg BD Warfarin targeting INR 2–3 | Inclusion criteria:
Exclusion criteria:
| 1, 3, 6 months | Primary outcome: Resolution of LVT in 3 months Secondary outcomes: Resolution of LVT in 6 months Safety outcome: MACE or any relevant bleeding according to the BARC classification |
Mansouri et al. 2024 [16] | n = 52 Iran | open- label non-inferiority RCT Rivaroxaban 20 mg daily Warfarin 5 mg loading dose aiming INR 2–3 | Inclusion criteria:
Exclusion criteria:
| 3 months | Primary outcome: Resolution of LVT on TTE in 3 months Secondary outcomes: Bleeding Systemic embolic events Rehospitalization MACE Echocardiographic measures focusing on changes in thrombus size, mobility, and morphology |
Jenab et al. 2025 [11] | n = 50 Iran | Pilot, open-label, parallel-group RCT with a 1:1 allocation ratio, concealed allocation sequences, and blinded outcome assessments Rivaroxaban (15 mg daily) plus clopidogrel (75 mg daily) plus aspirin (80 mg daily, only during the first 7 days) Warfarin overlapping with enoxaparin, until reaching an INR goal of 2.0–2.5, plus clopidogrel (75 mg daily plus aspirin (80 mg daily, only during the first 7 days) | Inclusion criteria:
Exclusion criteria:
| 3 months | Primary outcome: 3-month non-contrast 2D TTE-based complete LVT resolution Other outcomes: SSE at 3 months MACE) at 3 months All-cause death at 3 months Main safety outcomes: Major bleeding events based on ISTH definition at 3 months |
RIVAWAR trial [12] | n = 261 Pakistan | Investigator initiated, single-center trial, open-label, RCT with a 2:1 allocation ratio Rivaroxaban 20 mg once daily Warfarin targeting INR 2–3 | Inclusion criteria:
Exclusion criteria:
| 3 months | Primary outcome: presence of LVT on TTE at 12 weeks post-randomization Secondary outcome: All-cause mortality Ischemic stroke Major bleeding |
2.5. Endpoints
2.6. Statistical Analysis
3. Results
3.1. LVT Resolution at 3 Months
3.2. Major or Clinically Significant Bleeding
3.3. Stroke or Thromboembolic Complications
3.4. Apixaban Versus Rivaroxaban for LVT Resolution at 3 Months
4. Discussion
Strengths and Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Magdy, J.; He, M.; Arockiam, S.; Harada, N.; Wheatcroft, S.B.; Bulluck, H. An Updated Meta-Analysis of Randomized Controlled Trials Comparing Direct Oral Anticoagulants Against Warfarin for Left Ventricular Thrombus Resolution. J. Clin. Med. 2025, 14, 6735. https://doi.org/10.3390/jcm14196735
Magdy J, He M, Arockiam S, Harada N, Wheatcroft SB, Bulluck H. An Updated Meta-Analysis of Randomized Controlled Trials Comparing Direct Oral Anticoagulants Against Warfarin for Left Ventricular Thrombus Resolution. Journal of Clinical Medicine. 2025; 14(19):6735. https://doi.org/10.3390/jcm14196735
Chicago/Turabian StyleMagdy, Joseph, Maggie He, Sacchin Arockiam, Nanami Harada, Stephen B. Wheatcroft, and Heerajnarain Bulluck. 2025. "An Updated Meta-Analysis of Randomized Controlled Trials Comparing Direct Oral Anticoagulants Against Warfarin for Left Ventricular Thrombus Resolution" Journal of Clinical Medicine 14, no. 19: 6735. https://doi.org/10.3390/jcm14196735
APA StyleMagdy, J., He, M., Arockiam, S., Harada, N., Wheatcroft, S. B., & Bulluck, H. (2025). An Updated Meta-Analysis of Randomized Controlled Trials Comparing Direct Oral Anticoagulants Against Warfarin for Left Ventricular Thrombus Resolution. Journal of Clinical Medicine, 14(19), 6735. https://doi.org/10.3390/jcm14196735