Left ventricular thrombus (LVT) formation in patients with acute myocardial infarction (AMI) or cardiomyopathies is not uncommon. The optimal oral anticoagulation therapy for resolving LVT has been under intense debate. Vitamin K antagonists (VKAs) remain the anticoagulant of choice for this condition, according to practice guidelines. Evidence supporting the use of direct oral anticoagulants (DOACs) in the management of LVT continues to grow. We performed a systematic review and meta-analysis to compare the efficacy and safety of DOACs versus VKAs. A comprehensive literature search was carried out in PubMed, Cochrane Library, Web of Science, Embase, and Scopus databases in July 2023. The efficacy outcomes of this study were thrombus resolution, ischemic stroke, systemic embolism, stroke/systemic embolism, all-cause mortality, and adverse cardiovascular events. The safety outcomes were any bleeding, major bleeding, and intracranial hemorrhage. A total of twenty-seven eligible studies were included in the meta-analysis. Data were analyzed utilizing Stata software version 15.1. There was no significant difference between DOACs and VKAs with regard to LVT resolution (RR = 1.00, 95% CI 0.95–1.05, P = 0.99). In the overall analysis, DOACs significantly reduced the risk of stroke (RR = 0.74, 95% CI 0.57–0.96, P = 0.021), all-cause mortality (RR = 0.70, 95% CI 0.57–0.86, P = 0.001), any bleeding (RR = 0.75, 95% CI 0.61–0.92, P = 0.006) and major bleeding (RR = 0.67, 95% CI 0.52–0.85, P = 0.001) when compared to VKAs. Meanwhile, in the sub-analysis examining randomized controlled trials (RCTs), the aforementioned outcomes no longer differed significantly between the DOACs and VKAs groups. The incidences of systemic embolism (RR = 0.81, 95% CI 0.54–1.22, P = 0.32), stroke/systemic embolism (RR = 0.85, 95% CI 0.72–1.00, P = 0.056), intracranial hemorrhage (RR = 0.59, 95% CI 0.23–1.54, P = 0.28), and adverse cardiovascular events (RR = 0.99, 95% CI 0.63–1.56, P = 0.92) were comparable between the DOACs and VKAs groups. A subgroup analysis showed that patients treated with rivaroxaban had a significantly lower risk of stroke (RR = 0.24, 95% CI 0.08–0.72, P = 0.011) than those in the VKAs group. With non-inferior efficacy and superior safety, DOACs are promising therapeutic alternatives to VKAs in the treatment of LVT. Further robust investigations are warranted to confirm our findings.

中文翻译：

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DOAC 与 VKA 治疗左心室血栓的有效性和安全性比较——荟萃分析更新

急性心肌梗死 (AMI) 或心肌病患者形成左心室血栓 (LVT) 并不罕见。解决 LVT 的最佳口服抗凝疗法一直存在激烈争论。根据实践指南，维生素 K 拮抗剂 (VKA) 仍然是这种情况的首选抗凝剂。支持使用直接口服抗凝剂 (DOAC) 治疗 LVT 的证据持续增加。我们进行了系统回顾和荟萃分析，以比较 DOAC 与 VKA 的有效性和安全性。2023 年 7 月在 PubMed、Cochrane Library、Web of Science、Embase 和 Scopus 数据库中进行了全面的文献检索。该研究的疗效结果为血栓消退、缺血性卒中、全身性栓塞、卒中/全身性栓塞、全因死亡率和不良心血管事件。安全性结果是任何出血、大出血和颅内出血。荟萃分析中总共纳入了二十七项符合条件的研究。使用 Stata 软件版本 15.1 分析数据。DOAC 和 VKA 在 LVT 分辨率方面没有显着差异（RR = 1.00，95% CI 0.95–1.05，P = 0.99）。在总体分析中，DOAC 显着降低了中风风险（RR = 0.74，95% CI 0.57-0.96，P = 0.021）、全因死亡率（RR = 0.70，95% CI 0.57-0.86，P = 0.001）、与 VKA 相比，任何出血（RR = 0.75，95% CI 0.61–0.92，P = 0.006）和大出血（RR = 0.67，95% CI 0.52–0.85，P = 0.001）。与此同时，在随机对照试验 (RCT) 的子分析中，上述结果在 DOAC 组和 VKA 组之间不再存在显着差异。全身性栓塞（RR = 0.81，95% CI 0.54-1.22，P = 0.32）、卒中/全身性栓塞（RR = 0.85，95% CI 0.72-1.00，P = 0.056）、颅内出血（RR = 0.59， DOAC 组和 VKA 组之间的 95% CI 0.23–1.54，P = 0.28）和不良心血管事件（RR = 0.99，95% CI 0.63–1.56，P = 0.92）具有可比性。亚组分析显示，接受利伐沙班治疗的患者卒中风险显着低于 VKA 组患者（RR = 0.24，95% CI 0.08-0.72，P = 0.011）。DOAC 具有不逊色的疗效和卓越的安全性，是治疗 LVT 时 VKA 的有前途的治疗替代品。有必要进行进一步强有力的调查来证实我们的发现。