LV thrombus
LV thrombus.
Background :
Although the incidence of left ventricular (LV) thrombus following acute myocardial infarction (AMI) has declined significantly due to early use of primary percutaneous coronary intervention (PCI) and modern antithrombotic therapy, it remains a clinically important complication due to the high risk of stroke and systemic embolism. Current American guidelines recommend vitamin K antagonists (VKAs) over direct oral anticoagulants (DOACs) for preventing embolic events in patients with AMI complicated by LV thrombus.
Diagnostic tools include transthoracic echocardiography (with or without contrast agents) and cardiac magnetic resonance imaging. Transesophageal echocardiography (TEE) is the gold standard technique for detecting thrombus of the left atrium or left atrial appendage although TTE is also widely used for excluding LV thrombus in patients with acute ischemic stroke().
Most LV thrombi form within two weeks after MI, and routine surveillance imaging appears to have limited value. Current data do not support routine prophylactic anticoagulation, even in high-risk patients.
The incidence of LV thrombus following anterior ST-elevation myocardial infarction (STEMI) varies widely (4%–39%) and may be underestimated due to limited use of CMR. While incidence has declined due to better reperfusion strategies, risk remains considerable. In patients with dilated cardiomyopathy (DCM), the incidence ranges from 2% to 36%, and risk has not significantly decreased. LV thrombus carries a high risk of embolic events (up to 22%) and major adverse cardiovascular events (up to 37%).
The management is further complicated by data showing that combining oral anticoagulants (OACs) with dual antiplatelet therapy (DAPT) increases bleeding risk in patients undergoing PCI for other conditions like atrial fibrillation or mechanical valves. Emerging evidence supports a tailored regimen using a DOAC with a single antiplatelet agent, though this approach has not been evaluated in randomized trials for post-AMI LV thrombus.
Source: Advancing clinical management of left ventricular thrombosis: prevention, detection and treatment modalities in the modern era https://heart.bmj.com/content/early/2025/03/05/heartjnl-2024-324605