Stanislav Henkin

Background: Left ventricular thrombus (LVT) is a serious thromboembolic complication of cardiac dysfunction. Vitamin K antagonists (VKAs) are the historical standard therapy, but have limitations. While direct oral anticoagulants (DOACs) offer practical advantages, their efficacy and safety in LVT remain uncertain. This meta-analysis aimed to compare the efficacy and safety of DOACs versus VKAs for the treatment of LVT. Methods: We conducted a meta-analysis by systematically searching electronic databases from inception to December 2025. A random-effects model was used for all analyses. The primary outcome was LVT resolution. Secondary outcomes included ischemic stroke, non-cerebral systemic embolism (SE), the composite of stroke and SE, any bleeding, major bleeding, and mortality. Results: A total of 35 studies (7 RCTs and 28 retrospective cohort studies), with 6,437 patients (DOACs n = 2,421, VKAs n = 4,016), were included in the analysis. DOACs showed a non-significant trend toward higher LVT resolution than VKAs (odds ratio [OR] 1.17; 95% confidence interval [CI] 0.99–1.39). DOACs were associated with a lower risk of stroke (OR 0.77, 95% CI 0.65–0.92), while SE rates remained comparable (OR 0.79, 95% CI 0.54–1.15). DOACs were associated with a significantly lower risk of major bleeding compared to VKAs (OR 0.62, 95% CI 0.48–0.79; p < 0.001). When analyses were limited to only randomized trials or post–acute coronary syndrome, efficacy and safety were similar across anticoagulants. Trial sequential analysis indicated indecisive results, highlighting the need for further clinical trials. Conclusions: DOACs showed overall efficacy similar to VKAs for the treatment of LVT, with lower rates of major bleeding. Despite the large number of included studies, the current evidence base remains inconclusive due to the predominance of observational studies, underscoring the need for additional large, well-designed clinical trials.

Post-pulmonary embolism syndrome (PPES) encompasses a diverse spectrum of long-term complications that are associated with persistent dyspnea, exercise intolerance, and a decrease in quality of life. The PPES constellation ranges from life-threatening conditions such as chronic thromboembolic pulmonary hypertension (CTEPH) to nonlife-threatening but still debilitating conditions such as chronic thromboembolic pulmonary disease (CTED) or post-PE deconditioning. The safety and efficacy of exercise and cardiopulmonary rehabilitation programs to prevent and manage these symptoms in PPES has not been well established. Herein, we review contributors to PPES and synthesize the evidence for exercise training after PE to treat and prevent PPES.