Direct oral anticoagulants versus warfarin for the management of left atrial appendage thrombus in patients with acute stroke.

Background: We compared the effectiveness of direct oral anticoagulants (DOACs) and warfarin for resolving left atrial appendage (LAA) thrombus in patients with acute stroke with non-valvular atrial fibrillation (NVAF).

Methods: Among consecutive patients with acute stroke admitted to five major comprehensive stroke centers in Japan between January 2017 and December 2022, those with NVAF and LAA thrombus detected by transesophageal echocardiography (TEE) and underwent follow-up TEE were included. All patients received DOAC or warfarin treatment. We compared the clinical characteristics, changes in LAA thrombus size, resolution, recurrent stroke, and bleeding complications within 3 months of stroke onset.

Results: This study included 63 patients (DOAC group, 22; warfarin group, 41). Sex, age, and National Institutes of Health Stroke Scale scores on admission did not significantly differ between the groups. The initial LAA thrombus size was 0.83 cm and 0.88 cm in the DOAC and warfarin groups, respectively. On follow-up evaluation 10 days after initial TEE, LAA thrombus was completely resolved in 59 % and 34 % of patients in the DOAC and warfarin groups, respectively (P = 0.02). Multivariable analysis revealed DOAC treatment as an independent factor for LAA thrombus resolution (odds ratio, 3.21; 95 % confidence interval: 1.07-10.23, P = 0.04). Recurrent stroke occurred in one and three patients in the DOAC and warfarin groups, respectively. No intracerebral hemorrhage cases were observed in either group within 3 months of stroke onset.

Conclusion: In patients with acute stroke with NVAF and LAA thrombus detected by TEE, DOACs may be more effective than warfarin in resolving LAA thrombus.