Left ventricular thrombus after acute myocardial infarction: Screening, prevention, and treatment

Cian P. McCarthy, Muthiah Vaduganathan, Killian J. McCarthy, James L. Januzzi, Deepak L. Bhatt, John W. McEvoy

Research output: Contribution to journalReview article

Abstract

IMPORTANCE Left ventricular (LV) thrombus is a complication of acutemyocardial infarction (MI) and is associated with systemic thromboembolism. With randomized clinical trials investigating the optimal antithrombotic regimen in patients with MI who require concomitant chronic anticoagulation and with the emergence of the direct-acting oral anticoagulants, treatment options for post-MI LV thrombus have become more complicated. Herein, we review the epidemiology, pathogenesis, diagnosis, prevention, and treatment of LV thrombus after acute MI. OBSERVATIONS Contemporary epidemiologic data suggest the incidence of LV thrombus, detected using optimal imaging modalities, may be as high as 15%in patients with ST-segment elevation MI and up to 25%in patients with anterior MI. While a standard transthoracic echocardiogram is commonly used for screening, it is limited by low sensitivity for LV thrombus detection, necessitating the addition of contrast (unless contraindicated) and/or use of cardiac magnetic resonance imaging when pretest probability is high. To our knowledge, there are no existing randomized clinical trials evaluating the safety and efficacy of anticoagulation in the prevention or treatment of LV thrombus after MI, and clinicians must rely on available epidemiologic and trial-generated data from related entities to guide treatment. Randomized clinical trials have confirmed that triple therapy increases bleeding rates compared with less potent antithrombotic regimens after MI, and observational data suggest that triple therapy regimens may not prevent LV thrombus formation. On the other hand, if an LV thrombus is detected, anticoagulation is essential to prevent systemic thromboembolism.We offer 1 approach to treatment, grounded in the best available data. CONCLUSIONS AND RELEVANCE Uncertainties remain regarding the optimal screening pathway, frequency of follow-up imaging, candidate selection for thromboprophylaxis, and treatment strategies for post-MI LV thrombus. Ongoing studies from related therapeutic areas of varying antithrombotic regimens will continue to inform the optimal approach to treatment; however, more dedicated study of this clinical conundrum is also needed.

Original languageEnglish (US)
Pages (from-to)642-649
Number of pages8
JournalJAMA Cardiology
Volume3
Issue number7
DOIs
StatePublished - Jul 1 2018

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Thrombosis
Myocardial Infarction
Therapeutics
Randomized Controlled Trials
Thromboembolism
Anticoagulants
Infarction
Patient Selection
Uncertainty
Epidemiology
Magnetic Resonance Imaging
Hemorrhage
Safety
Incidence

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

McCarthy, C. P., Vaduganathan, M., McCarthy, K. J., Januzzi, J. L., Bhatt, D. L., & McEvoy, J. W. (2018). Left ventricular thrombus after acute myocardial infarction: Screening, prevention, and treatment. JAMA Cardiology, 3(7), 642-649. https://doi.org/10.1001/jamacardio.2018.1086

Left ventricular thrombus after acute myocardial infarction : Screening, prevention, and treatment. / McCarthy, Cian P.; Vaduganathan, Muthiah; McCarthy, Killian J.; Januzzi, James L.; Bhatt, Deepak L.; McEvoy, John W.

In: JAMA Cardiology, Vol. 3, No. 7, 01.07.2018, p. 642-649.

Research output: Contribution to journalReview article

McCarthy, CP, Vaduganathan, M, McCarthy, KJ, Januzzi, JL, Bhatt, DL & McEvoy, JW 2018, 'Left ventricular thrombus after acute myocardial infarction: Screening, prevention, and treatment', JAMA Cardiology, vol. 3, no. 7, pp. 642-649. https://doi.org/10.1001/jamacardio.2018.1086
McCarthy CP, Vaduganathan M, McCarthy KJ, Januzzi JL, Bhatt DL, McEvoy JW. Left ventricular thrombus after acute myocardial infarction: Screening, prevention, and treatment. JAMA Cardiology. 2018 Jul 1;3(7):642-649. https://doi.org/10.1001/jamacardio.2018.1086
McCarthy, Cian P. ; Vaduganathan, Muthiah ; McCarthy, Killian J. ; Januzzi, James L. ; Bhatt, Deepak L. ; McEvoy, John W. / Left ventricular thrombus after acute myocardial infarction : Screening, prevention, and treatment. In: JAMA Cardiology. 2018 ; Vol. 3, No. 7. pp. 642-649.
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AB - IMPORTANCE Left ventricular (LV) thrombus is a complication of acutemyocardial infarction (MI) and is associated with systemic thromboembolism. With randomized clinical trials investigating the optimal antithrombotic regimen in patients with MI who require concomitant chronic anticoagulation and with the emergence of the direct-acting oral anticoagulants, treatment options for post-MI LV thrombus have become more complicated. Herein, we review the epidemiology, pathogenesis, diagnosis, prevention, and treatment of LV thrombus after acute MI. OBSERVATIONS Contemporary epidemiologic data suggest the incidence of LV thrombus, detected using optimal imaging modalities, may be as high as 15%in patients with ST-segment elevation MI and up to 25%in patients with anterior MI. While a standard transthoracic echocardiogram is commonly used for screening, it is limited by low sensitivity for LV thrombus detection, necessitating the addition of contrast (unless contraindicated) and/or use of cardiac magnetic resonance imaging when pretest probability is high. To our knowledge, there are no existing randomized clinical trials evaluating the safety and efficacy of anticoagulation in the prevention or treatment of LV thrombus after MI, and clinicians must rely on available epidemiologic and trial-generated data from related entities to guide treatment. Randomized clinical trials have confirmed that triple therapy increases bleeding rates compared with less potent antithrombotic regimens after MI, and observational data suggest that triple therapy regimens may not prevent LV thrombus formation. On the other hand, if an LV thrombus is detected, anticoagulation is essential to prevent systemic thromboembolism.We offer 1 approach to treatment, grounded in the best available data. CONCLUSIONS AND RELEVANCE Uncertainties remain regarding the optimal screening pathway, frequency of follow-up imaging, candidate selection for thromboprophylaxis, and treatment strategies for post-MI LV thrombus. Ongoing studies from related therapeutic areas of varying antithrombotic regimens will continue to inform the optimal approach to treatment; however, more dedicated study of this clinical conundrum is also needed.

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