2022 循证建议：急性心肌梗死后左室血栓的管理

$\bullet$ PATHOPHYSIOLOGY

Left ventricular thrombus formation depends on multiple factors such as blood stasis, myocardial tissue injury, and hypercoagulability, known as Virchow triad. 2 Blood stasis in the weak noncontractile segment is a key contributing factor in thrombus formation. 2,10 (Figure 1 shows the interplay of all these factors in LVT formation.)

$\bullet$ DIAGNOSIS

Transthoracic echocardiography (TTE) has been widely used as the diagnostic tool of choice in evaluating LVT. 11 However, because of its low sensitivity, echocardiography tends to underestimate the incidence of LVT. 11 As per Gianstefani et al, 3 thrombi missed by TTE were smaller in size and located at the apex. Therefore, the use of echocardiographic contrast agents (ECAs) has been recommended to improve TTE sensitivity in detecting LVT. 12,13

 Figure 1. The interplay of risk factors in LVT formation. LVT, left ventricular thrombus. Adapted from Cruz Rodriguez et al. 10

In a study, ECA use has been reported to be more costeffective and precise in LVT detection than TTE. 13

Cardiac magnetic resonance (CMR) is considered the criterion standard for diagnosing LVT. 14,15 In a serial study by Phan et al, 16 210 STEMI patients underwent CMR and TTE with appropriate follow-up. The findings were such that LVT detection by TTE occurred in $6.2\%$ of patients, whereas CMR detected $12.3\,\%$ . Phan et al 16 concluded that echocardiography had $50\%$ sensitivity and $100\%$ specificity for LVT detection compared with CMR. In a separate study, Weinsaft et $a1^{12}$ found similar results with TTE sensitivity of $35\%$ , whereas contrast echo image quality and sensitivity improved to $64\%$ compared with CMR. Noteworthy is that one-third of thrombi found by CMR were undetected by both types of echocardiography. 12 Studies also showed that CMR with gadolinium facilitates immediate and pronounced enhancement of the LV cavity, allowing the detection of any intraventricular structural abnormalities. 12-14

According to Weinsaft et al, 15 LVT was more likely to be found in areas with increased myocardial scarring, a parameter that can only be evaluated with delayed enhancement CMR. Despite CMR diagnostic superiority, it cannot be performed on all MI cases because of cost constraints, time efficacy, and availability. A more timely and practical approach to improve diagnostic sensitivity is to perform TTE in all patients with MI. 17 Use of ECAs or CMR should be used in patients with poor ultrasound windows and in patients with apical wall motion abnormality. 12-14 An alternative approach is to perform contrast CMR in all patients with reduced apical wall motion on

noncontrast echo, to detect all LVT after MI. 17 This approach, as illustrated, is deemed to have near-certain confidence in LVT detection. (Figure 2 is an illustration of this approach.) Although Cruz Rodriguez and colleagues' 10 literature review concluded that computed tomography scanning provides approximately $100\%$ specificity and $80\%$ sensitivity, the computed tomography technique is not used in practice given the undesirable exposure to radiographic materials. 10

Left ventricular thrombus is thought to form usually within the first 2 weeks following STEMI, but delayed thrombus formation at 4 to 6 months post-STEMI has also been reported. 18 From the study by Cambronero-Cortinas et al, 18 $33\,\%$ of new LVT cases were detected at 6 months with CMR. This finding suggests that repeat imaging is needed in high-risk patients.

## EMBOLIC COMPLICATIONS OF LVT

Most embolic events due to LVToccur within the first 3 to 4 months after MI. 2 Several studies have established that irregularly shaped, protruding, and/or mobile LVT is associated with a higher rate of embolization than thrombi without these features. 16,19,20 Other thrombus characteristics may increase the risk for embolization such as thrombus area, length of the thrombus in the lumen, and LVT recurrence. 14,21,22 Conversely, older thrombus identified as laminated, immobile, and echo-dense structures tends to be chronic and less likely to embolize. 22 However, embolization risk still exists for these laminar thrombi. 10

Certain evidence suggests that LVT resolution documented by imaging does not safeguard against the possibility of future stroke. Left ventricular thrombus should be considered as a marker of increased long-term thrombotic risk due to its association with procoagulation. 20,23 Leow et al 20 examined 289 LVT patients after AMI receiving treatment with triple therapy $(\boldsymbol{\mathrm{n}}=185$ ) or warfarin only

$(\boldsymbol{\mathrm{n}}=247\$ ) and evaluated acute ischemic stroke as a primary outcome. Acute ischemic stroke was reported in $11.8\,\%$ of patients, with nearly half of them not on AC at the time of stroke. 20 The median time for the diagnosis of a cerebrovascular event was 20.5 days. 20 Despite the initial thrombus resolution, acute ischemic stroke occurred in 9 patients $(5.2\%)$ . Most strokes $(76.5\%)$ were described as cardioembolic, followed by $14.7\%$ as a small vessel disease and $8.8\,\%$ as large artery atherosclerosis. 20 The presence of thrombus protrusion, failure of initial thrombus resolution, and thrombus recurrence were recognized as significant independent stroke indicators. 20 Lattuca et $\mathfrak{a l}^{22}$ also found no significant difference in embolic complications between patients with or without LVT resolution. These embolic complications can occur under AC therapy because of thrombus fragmentation, quick thrombus resolution, or the persistence of the thrombus. 22 The contemporary cohort study by Lattuca et al 22 also showed that 4 of 10 patients had a major cardiovascular event, and 1 of 5 died during the follow-up period. Noteworthy, these figures are much higher than the reported STEMI without LVT. 22 Other conditions that increase the risk of systemic embolization include heart failure, diffuse LV dilatation and systolic dysfunction, previous embolization, atrial fibrillation (AF), and advanced patient age. 10

MANAGEMENT

Triple Therapy

Following the diagnosis of STEMI, DAPT (aspirin and $\mathrm{P}2\mathrm{Y}_{12}$ inhibitors) is usually initiated to prevent further ischemic events. 4 However, the effects of the routine DAPT therapy in reducing LVT are less understood as these agents have a minimal inhibitory effect on thrombin and fibrinogen formation. 2 Thus, the standard of care for LVT management is AC with or without the addition of

 Figure 2. Step-by-step approach to diagnosis. Adapted from Bulluck et al. 17

DAPT. 4 Anticoagulation is recommended to reduce LVT embolic complications and support the innate fibrinolytic mechanisms to resolve the thrombus. 2 According to the 2018 update of the Canadian Cardiovascular Society/ Canadian Association of Interventional Cardiology antiplatelet guidelines, Mehta et al 4 recommended the initiation of a triple therapy regimen consisting of acetylsalicylic acid $81~\mathrm{{mg}}$ daily, clopidogrel 75 mg daily (DAPT), and warfarin as the only oral anticoagulant recommended to manage LVT. Treatment of LVT with VKAs varies from a minimum of 3 months to up to 1 year, with duration individualized to LVT resolution and bleeding risk. 4 Repeat imaging is suggested at the end of the treatment period to evaluate the resolution of LVT. However, this combination is associated with a significant risk of bleeding and poor long-term outcomes. In the retrospective study by Le May et al, 24 460 patients with apical akinesis or dyskinesis after STEMI had undergone primary PCI and received DAPT with $(\boldsymbol{\mathrm{n}}=131$ ) and without $(\mathbf{n}=329$ ) warfarin. Patients in the warfarin group experienced a net increase in adverse clinical events (all-cause mortality, strokes, reinfarction, and major bleeding) at 180 days compared with those in the no-warfarin group $.14.7\%$ vs $4.6\%$ , $P\;=$ .001). 24 The study by Belliveau et $a1^{25}$ also found a substantial risk of bleeding $(18.5\%)$ related to the use of the triple therapy with a mean duration of 6.4 months, even though the risk of cardioembolic events was low.

Warfarin and the Use of Heparin

Patients with LVT treated with warfarin require bridging with intravenous heparin or subcutaneous low-molecularweight heparin until their international normalized ratio (INR) is within the therapeutic range of 2.0 to 3.0. 10 There are limited data in comparing the efficacy of parenteral agents versus warfarin. White et al 26 conducted a randomized pilot trial $(\mathtt{n}=60)$ ) in patients with anterior MI with Q waves and EF ${\leq}40\%$ comparing the effectiveness of enoxaparin $.1\,\mathrm{mg/kg}$ twice a day; maximum dose, $100\;\mathrm{mg},$ ) to unfractionated heparin followed by oral warfarin for 3 months. The preventive full therapeutic dose of enoxaparin for 30 days had similar bleeding and thromboembolic events compared with the AC with warfarin. More patients had probable mural thrombus at 3.5 months with enoxaparin, albeit the difference was not statistically significant. 26

DOACs as Alternatives for VKA

Even though the current recommendation is VKA for LVT management, warfarin is sometimes contraindicated in certain patients, which warrants the providers to use other AC such as DOACs. These novel drugs selectively inhibit thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban, and edoxaban). 5 Direct-acting oral

anticoagulants are better alternatives for VKAs based on its many advantages — specifically the ease of administration (2-4 hours to reach peak plasma levels and their half-lives of 8- -12 hours), lack of requirement for INR monitoring, no need for dietary restrictions, minimal drug interactions, and the overall improvement in quality of life. 19,27,28 Their uses also have shown strong evidence in managing patients with nonvalvular AF and venous thromboembolism in preventing stroke and systemic embolism with an improved bleeding profile in comparison to warfarin. 29 Therefore, the “ offlabel ” use of DOACs has recently gained interest as a potential prospective in managing LVT patients. However, the safety profile and therapeutic efficacy of DOACs remain debatable, largely attributed to inconsistent results from several observational studies and the lack of large randomized controlled trials (RCTs) to study optimal LVT management strategies. 2,10,29,30 In a large multicenter retrospective cohort study $(\boldsymbol{\mathrm{n}}=514$ ), Robinson et $a\!\!\!\mid^{23}$ reported that DOAC treatment $(43.9\%$ of the total cohort) had an increased risk of stroke or systemic embolism at a median of 351 days of follow-up. Conversely, Michael and colleagues' 29 meta-analysis of 16 cohort studies plus 2 RCTs identified a reduced risk of stroke with DOACs as compared with VKA without an increase in bleeding occurrences. Based on their results, Michael et al 29 concluded that DOACs are a reasonable and valid alternative option to VKA for the management of LVT.

Efficacy and Safety of DOACs Versus VKA in Thrombus Resolution

Several studies and meta-analysis had compared the therapeutic efficacy and safety of DOACs versus warfarin for the treatment of LVT. The efficacy and safety outcomes were measured by thrombus resolution, stroke or systemic embolization, risks of bleeding complications, and mortality. They all reported similar efficacy and safety between DOAC and VKA in LVT. In Jaidka and colleagues' 7 study, DOACs showed a higher rate of LVT resolution compared with VKA $788.9\%$ vs $85.7\%$ ); however, this result did not reach statistical significance ( $P\,=\,.245,$ ). Further studies also indicated similar results of no significant difference in LVT resolution between DOACs and VKA. 5,27,30,31 It is also important to note that although the overall rate of LVT resolution was similar in the 2 groups in Ali and colleagues' 31 study, initial faster thrombus resolution was observed with the use of DOACs at the 1-month follow-up ( $.34\%$ vs $12\%$ , $P\,\leq\,.00001]$ ). Thus, further research is needed to investigate the time to thrombus solution in DOACs versus VKAs and its association with the risk of SSE. However, newer studies have recently favored DOACs over VKAs regarding LVT resolution. 30,32 Jones and colleagues' 30 study showed that the LVT resolution

was significantly higher in the DOAC group $(82\,\%)$ versus the VKA group $(64\%)$ . Similarly, Alizadeh and colleagues' 32 finding showed a greater and earlier LVTresolution in the DOAC group compared with the warfarin group ( $75\%$ vs $53\%$ , $P=.0018)$ ) at the 1-year follow-up.

DOACs Versus VKA in Terms of Stroke and Systemic Embolization

In terms of stroke, systemic embolization, or both, several studies 7,27,31-33 showed no significant difference between the 2 groups. For example, in Ali and colleagues' 31 singlecenter study $(\mathsf{n}=110)$ ), patients with LVT showed a lower 1-year risk of any stroke with DOACs in comparison to warfarin ( $12\%$ vs $6\%$ , $P=.33.$ ), although no statistical difference was found in ischemic stroke between warfarin and DOACs. Ali et $a l^{31}$ also reported that $71\%$ of patients who developed ischemic stroke were on warfarin and had a subtherapeutic INR. 31 Similarly, in Jones and colleagues' 30 study, nearly half of the warfarin group could not sustain a therapeutic INR, with all events occurring in these patients. Thus, it is unclear if higher odds of stroke or systemic embolism in those using VKAs are due to noncompliance, difficulty in maintaining therapeutic INR, or inherent differences in the anticoagulants themselves.

DOACs Versus VKA in Terms of Bleeding

Many studies 7,23,32-34 found similar bleeding outcomes between the DOAC and VKA groups with no statistical significance. Bass et al 33 observed comparable bleeding events $.10.9\%$ vs $7.8\,\%$ , $P=.40)$ ) between warfarin and DOAC, respectively. However, Jones et al 30 found an increased number of major bleeding events in patients receiving VKAs ( $\dot{\mathbf{\ell}}P=\,.030)$ in the context of triple antiplatelet therapy or DAPT including gastrointestinal bleeding, subarachnoid hemorrhage, and epistaxis requiring hospital admission. Furthermore, Bass et $a1^{33}$ examined rates of blood product administration between the 2 groups, reporting an increase among those receiving warfarin compared with those in the DOAC group $(25.8\%$ vs $13.9\%$ , $P<.001$ ).

DOACs Versus VKA in Terms of Mortality

Mortality was reported, and no study identified a meaningful difference between DOACs and VKAs. 5,23,27,34 In a meta-analysis by Dalia et al, 5 mortality was $9\%$ higher in patients receiving warfarin than those treated with DOAC (risk ratio, 1.09; $95\%$ confidence interval, 0.70-1.70; P = .48); however, the difference was not statistically significant.

Recent RCTs: DOACs Versus Warfarin

Recently, small-scale randomized trials have been reported showing the efficacy and safety of DOACs versus warfarin

in the management of LVT. Abdelnabi et $a l^{35}$ conducted a randomized controlled study comparing rivaroxaban and warfarin in the treatment of patients with LVT. Patients who met the inclusion criteria $\mathsf{\Omega}(\mathsf{n}\,=\,79)$ ) were randomly assigned to a 1:1 ratio to either dose-adjusted warfarin (bridging via enoxaparin $1~\mathrm{{mg/kg}}$ twice daily until reaching INR of 2-3) or rivaroxaban 20 mg daily. Transthoracic echocardiography was the diagnostic choice modality to assess LVT at 1, 3, and 6 months, respectively. Complete LVT resolution was the primary efficacy outcome in 28, 30, and 34 patients of the 39 patients $(71.79\%$ , $76.92\%$ , and $87.17\%$ ) in the rivaroxaban group. On the other hand, the warfarin group yielded complete LVT resolution in 19, 27, and 32 of 40 patients $(47.5\%$ , $67.5\%$ , and $80\%$ ) at 1, 3, and 6 months, respectively. 35 The occurrence of major bleeding was the primary safety outcome, with 2 patients $(5.1\%)$ ) identified in the rivaroxaban group and 6 patients $(15\%)$ in the warfarin group. Abdelnabi et al 35 concluded that rivaroxaban was at par efficacy and had faster thrombus resolution in comparison to warfarin. Their findings confirmed that DOACs are a reasonable alternative for LVT treatment.

In the second randomized clinical trial, 35 patients with LVT post-AMI were identified, with 17 patients treated with warfarin and 18 patients treated with apixaban. 36 Alcalai et al 36 reported no significant difference in LVT resolution between the 2 groups. However, no stroke or major bleeding occurred in the apixaban group compared with 3 patients in the warfarin group at the 3-month follow-up. 36 Similarly, Alcalai et al 36 concluded that apixaban is noninferior to warfarin in the management of LVT postAMI. Several limitations were noted in both studies such as small sample size, being unblinded, short follow-up, and the use of TTE for the LVT screening. 35,36 Thus, further larger RCTs in the future are needed to confirm the efficacy and safety of these agents.

Clinical Decisions

Current guidelines contain mostly low-grade recommendations that favor the use of warfarin along with DAPT in case of AMI to treat LVT unless contraindicated. 4 In general, the duration of therapy is greater than 3 months because of the higher rate of recurrence, but the optimal duration of the triple therapy remains unknown. 22 Therefore, the clinician should take into account the relative risk of bleeding, stent thrombosis, LVT resolution, and new LVT formation when considering the continuation or discontinuation of AC after repeating imaging at 3 months. 2 Discontinuation of AC would be based on no evidence of thrombus, especially if there is a recovery of apical wall motion. There is also ambiguity and lack of evidence on the cessation versus maintenance of AC in patients with

persistent LVT or wall motion abnormality. 2 Thus, the decision to maintain and cease warfarin or switch to different AC such as DOACs should be on a case-by-case basis after a risk-benefit discussion between the clinician and patient with a serial follow-up and repeat imaging. The clinician may order delayed enhancement CMR in these patients to differentiate between the new versus old thrombus and its potential for embolization and to assist in the decision-making process. Figure 3 serves as a flowchart to provide some guidance in the management of LVT patients. Preliminary data showed the effectiveness and safety of DOACs as a reasonable alternative to VKA for LVT management; however, the lack of standardized dosing and duration requires the clinician to be diligent at close monitoring and adjusting dosage accordingly as its effect on bleeding rates in the context of DAPT is not well studied. 2

$\bullet$ NURSING IMPLICATIONS AND MANAGEMENT OF PATIENTS WITH LVT RECEIVING AC

The primary treatment strategy for LVT patients is initiating AC therapy to prevent thromboembolic events without increasing the risk of bleeding. Nurses are essential in monitoring, assessing, managing, and educating patients on AC. Primary nursing interventions include monitoring patients' cardiovascular and neurological status (performing neurologic vital signs), recording dysrhythmias, and notifying clinicians of any changes. 37 Nurses should review patients' medical history to determine any contraindications before initiating AC therapy, such as active or high risk of bleeding, pregnancy, breastfeeding, renal or hepatic impairment, and cerebral aneurysm. 28 Nurses should monitor platelet count and coagulation levels (INR, prothrombin time, and partial thromboplastin time), especially with

warfarin, to ensure the dosing is in line with the therapeutic range. Anticoagulation might be paused temporarily, depending on the extent of the bleeding, while standard treatment, including reversal agents and support measures, was initiated. 28 The reinitiation of AC will depend on a risk-benefit assessment involving patients and families in the decision-making process. 28

Patients are empowered by educating them about their condition and treatment (regardless of the type of AC, VKA, or DOAC). Evidence suggests that the key barrier to patients' uptake and adherence is their lack of knowledge about their condition and treatment. 37,38 In a randomized trial known as the TREAT trial (Trial of an E ducational intervention on patients' knowledge of A trial fibrillation and anticoagulant therapy, I NR control, and outcome of T reatment with warfarin), Clarkesmith et al 38 examined the influence of a theory-driven educational intervention on the therapeutic range (TTR) and other outcomes, including patient knowledge, illness perceptions, beliefs about medications, and perceived benefits and burdens of warfarin, compared with patients with AF receiving usual care alone. Their findings showed that the TREAT intervention patients had a significantly higher TTR than usual care at 6 months ( $\dot{}P=.035)$ ), and patients' knowledge increased significantly across time $(\,P\,<\,.01)$ about their illness and treatment, leading to the maintenance of TTR. 38 Clarkesmith et al 38 emphasized the importance of patient education in making a significant difference in long-term adherence. Educating patients about some life changes such as alcohol consumption, dietary restrictions, and other herbal supplements will provide an understanding of changes that need to be made to offset the anticoagulant effects. 28,37 Environmental changes will also be needed to be addressed to help prevent injury and reduce the risk of bleeding when on AC. 28

 Figure 3. Management flowchart approach. Adapted from Habash and Vallurupalli. 2

$\bullet$ CONCLUSION

Left ventricular thrombus is a severe complication of AMI with severe adverse effects such as stroke and systemic embolism. Current low-evidence guidelines recommended triple therapy, including DAPTand VKA, in the management of LVT post-AMI even with their high risk of bleeding. Direct-acting oral anticoagulants are preferred alternatives for VKAs because of their potential efficacy and safety. Thus, further prospective trials are needed to confirm the efficacy and safety of these agents and clarify the optimum duration of the AC in the treatment of these patients. A review of the “ bundle ” of care recommendations during huddles, orientation, grand rounds, or other events will contribute significantly to the decision-making process for patients with LVT post-AMI. This work could also serve as inspiration for new research or quality improvement work in the care of this patient population.

References

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ABOUT THE AUTHORS

Mohamed Toufic El Hussein, PhD, RN, NP, is professor, School of Nursing and Midwifery, Faculty of Health, Community and Education, Mount Royal University; and acute care nurse practitioner, Medical Cardiology, Coronary Care Unit, Rockyview General Hospital, Calgary, Alberta, Canada. With a career in academia spanning over two decades, Dr. Mohamed El Hussein, NP, PhD, professor in the School of Nursing and

Midwifery at MRU, is a significant contributor to the profession of nursing and the scholarship of teaching and learning. El Hussein ’ s research focuses on understanding how students learn and creating strategies to support learning of complex concepts. Care of older adults is another pillar of El Hussien ’ s program of research where he explores barriers and facilitators to recognizing delirium and dementia in acute care settings. To support clinical education, El Hussein created and validated tools to better evaluate students ’ performance in practical courses. In addition to generating relevant knowledge, his scholarship yielded several knowledge translation vehicles to simplify the interpretation and application of clinical practice guidelines. To stay clinically up to date, Dr. El Hussein works as a Nurse Practitioner in the division of cardiology at the Rockyview General Hospital. Marianne Mikhail, RN, Department of Emergency Medicine, Alberta Health Services, Edmonton, Canada. Marianne Mikhail is an ED nurse with more than 10 years experience in critical care nursing. Research interests include cardiovascular disorder especially arrhythmias and advanced practice nursing. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. All authors have read and approved the submitted version of the manuscript. Development of the manuscript and any research reported therein have adhered to ethical standards. Address correspondence and reprint requests to: Mohamed Toufic El Hussein, PhD, RN, NP, Mount Royal University, 4825 Mount Royal Gate S. W., Calgary, AB T3E 6K6, Office Y456, Alberta, Canada (melhussein@mtroyal.ca).

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