Skip to main content
PMC home page
Postgraduate Medical Journal logoLink to Postgraduate Medical Journal
. 1996 Dec;72(854):731–738. doi: 10.1136/pgmj.72.854.731

Intracardiac thrombus formation in cardiac impairment: the role of anticoagulant therapy.

G Y Lip 1
PMCID: PMC2398676  PMID: 9015466

Abstract

The presence of intracardiac thrombus has been associated with many diseases and clinical states, although cardiac impairment is commonly also present. Despite this, there continues to be a lack of consensus on which patients with cardiac impairment should have anticoagulant therapy. This review discusses the relationship between thromboembolism and cardiac impairment secondary to ischaemic heart disease, and suggests possible mechanisms, methods of diagnosis and therapeutic strategies for anticoagulation in such patients. In particular, warfarin has been established as thromboprophylaxis in certain subgroups of patients with cardiac impairment secondary to ischaemic heart disease. A large-scale randomised controlled trial in ambulant patients with cardiac impairment to evaluate the effectiveness of anticoagulant therapy and antiplatelet therapy is, however, long overdue.

Full text

PDF
735

Images in this article

734Figure
on p.734

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Anticoagulants in acute myocardial infarction. Results of a cooperative clinical trial. JAMA. 1973 Aug 13;225(7):724–729. [PubMed] [Google Scholar]
  2. Asinger R. W., Mikell F. L., Sharma B., Hodges M. Observations on detecting left ventricular thrombus with two dimensional echocardiography: emphasis on avoidance of false positive diagnoses. Am J Cardiol. 1981 Jan;47(1):145–156. doi: 10.1016/0002-9149(81)90303-9. [DOI] [PubMed] [Google Scholar]
  3. Baker D. W., Wright R. F. Management of heart failure. IV. Anticoagulation for patients with heart failure due to left ventricular systolic dysfunction. JAMA. 1994 Nov 23;272(20):1614–1618. doi: 10.1001/jama.272.20.1614. [DOI] [PubMed] [Google Scholar]
  4. Cabin H. S., Roberts W. C. Left ventricular aneurysm, intraaneurysmal thrombus and systemic embolus in coronary heart disease. Chest. 1980 May;77(5):586–590. doi: 10.1378/chest.77.5.586. [DOI] [PubMed] [Google Scholar]
  5. Cleland J. G., Bulpitt C. J., Falk R. H., Findlay I. N., Oakley C. M., Murray G., Poole-Wilson P. A., Prentice C. R., Sutton G. C. Is aspirin safe for patients with heart failure? Br Heart J. 1995 Sep;74(3):215–219. doi: 10.1136/hrt.74.3.215. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Cregler L. L. Antithrombotic therapy in left ventricular thrombosis and systemic embolism. Am Heart J. 1992 Apr;123(4 Pt 2):1110–1114. doi: 10.1016/0002-8703(92)91069-d. [DOI] [PubMed] [Google Scholar]
  7. Delemarre B. J., Visser C. A., Bot H., Dunning A. J. Prediction of apical thrombus formation in acute myocardial infarction based on left ventricular spatial flow pattern. J Am Coll Cardiol. 1990 Feb;15(2):355–360. doi: 10.1016/s0735-1097(10)80062-2. [DOI] [PubMed] [Google Scholar]
  8. Ezekowitz M. D., Wilson D. A., Smith E. O., Burow R. D., Harrison L. H., Jr, Parker D. E., Elkins R. C., Peyton M., Taylor F. B. Comparison of Indium-111 platelet scintigraphy and two-dimensional echocardiography in the diagnosis of left ventricular thrombi. N Engl J Med. 1982 Jun 24;306(25):1509–1513. doi: 10.1056/NEJM198206243062502. [DOI] [PubMed] [Google Scholar]
  9. Falk R. H., Foster E., Coats M. H. Ventricular thrombi and thromboembolism in dilated cardiomyopathy: a prospective follow-up study. Am Heart J. 1992 Jan;123(1):136–142. doi: 10.1016/0002-8703(92)90757-m. [DOI] [PubMed] [Google Scholar]
  10. Furlan A. J., Craciun A. R., Raju N. R., Hart N. Cerebrovascular complications associated with idiopathic hypertrophic subaortic stenosis. Stroke. 1984 Mar-Apr;15(2):282–284. doi: 10.1161/01.str.15.2.282. [DOI] [PubMed] [Google Scholar]
  11. Fuster V., Gersh B. J., Giuliani E. R., Tajik A. J., Brandenburg R. O., Frye R. L. The natural history of idiopathic dilated cardiomyopathy. Am J Cardiol. 1981 Mar;47(3):525–531. doi: 10.1016/0002-9149(81)90534-8. [DOI] [PubMed] [Google Scholar]
  12. GRIFFITH G. C., STRAGNELL R., LEVINSON D. C., MOORE F. J., WARE A. G. A study of the beneficial effects of anticoagulant therapy in congestive heart failure. Ann Intern Med. 1952 Nov;37(5):867–887. doi: 10.7326/0003-4819-37-5-867. [DOI] [PubMed] [Google Scholar]
  13. Gottdiener J. S., Gay J. A., VanVoorhees L., DiBianco R., Fletcher R. D. Frequency and embolic potential of left ventricular thrombus in dilated cardiomyopathy: assessment by 2-dimensional echocardiography. Am J Cardiol. 1983 Dec 1;52(10):1281–1285. doi: 10.1016/0002-9149(83)90588-x. [DOI] [PubMed] [Google Scholar]
  14. HARVEY W. P., FINCH C. A. Dicumarol prophylaxis of thromboembolic disease in congestive heart failure. N Engl J Med. 1950 Feb 9;242(6):208–211. doi: 10.1056/NEJM195002092420603. [DOI] [PubMed] [Google Scholar]
  15. Hardarson T., De la Calzada C. S., Curiel R., Goodwin J. F. Prognosis and mortality of hypertrophic obstructive cardiomyopathy. Lancet. 1973 Dec 29;2(7844):1462–1467. doi: 10.1016/s0140-6736(73)92730-x. [DOI] [PubMed] [Google Scholar]
  16. Haugland J. M., Asinger R. W., Mikell F. L., Elsperger J., Hodges M. Embolic potential of left ventricular thrombi detected by two-dimensional echocardiography. Circulation. 1984 Oct;70(4):588–598. doi: 10.1161/01.cir.70.4.588. [DOI] [PubMed] [Google Scholar]
  17. Higgins C. B., Byrd B. F., 2nd, McNamara M. T., Lanzer P., Lipton M. J., Botvinick E., Schiller N. B., Crooks L. E., Kaufman L. Magnetic resonance imaging of the heart: a review of the experience in 172 subjects. Radiology. 1985 Jun;155(3):671–679. doi: 10.1148/radiology.155.3.3159039. [DOI] [PubMed] [Google Scholar]
  18. Husted S., Andreasen F. Problems encountered in long-term treatment with anticoagulants. Acta Med Scand. 1976;200(5):379–384. doi: 10.1111/j.0954-6820.1976.tb08250.x. [DOI] [PubMed] [Google Scholar]
  19. Iga K., Matsuo M., Tsuji A., Nishiki S., Hori K., Matsumura T., Gen H., Tamamura T. [Usefulness of magnetic resonance imaging (MRI) in evaluation of left ventricular apical aneurysm]. Kokyu To Junkan. 1992 Jun;40(6):593–597. [PubMed] [Google Scholar]
  20. Jafri S. M., Ozawa T., Mammen E., Levine T. B., Johnson C., Goldstein S. Platelet function, thrombin and fibrinolytic activity in patients with heart failure. Eur Heart J. 1993 Feb;14(2):205–212. doi: 10.1093/eurheartj/14.2.205. [DOI] [PubMed] [Google Scholar]
  21. Johannessen K. A., Nordrehaug J. E., von der Lippe G. Increased occurrence of left ventricular thrombi during early treatment with timolol in patients with acute myocardial infarction. Circulation. 1987 Jan;75(1):151–155. doi: 10.1161/01.cir.75.1.151. [DOI] [PubMed] [Google Scholar]
  22. Keating E. C., Gross S. A., Schlamowitz R. A., Glassman J., Mazur J. H., Pitt W. A., Miller D. Mural thrombi in myocardial infarctions. Prospective evaluation by two-dimensional echocardiography. Am J Med. 1983 Jun;74(6):989–995. doi: 10.1016/0002-9343(83)90798-2. [DOI] [PubMed] [Google Scholar]
  23. Kessler K. M. Predictors of left ventricular thrombus formation: flow, asynergy and morphology. J Am Coll Cardiol. 1990 Feb;15(2):361–362. doi: 10.1016/s0735-1097(10)80063-4. [DOI] [PubMed] [Google Scholar]
  24. Kontny F., Dale J., Abildgaard U., Hegrenaes L., Lem P., Morstøl T. Adverse effect of warfarin in acute myocardial infarction: increased left ventricular thrombus formation in patients not treated with high-dose heparin. Eur Heart J. 1993 Aug;14(8):1040–1043. doi: 10.1093/eurheartj/14.8.1040. [DOI] [PubMed] [Google Scholar]
  25. Kyrle P. A., Korninger C., Gössinger H., Glogar D., Lechner K., Niessner H., Pabinger I. Prevention of arterial and pulmonary embolism by oral anticoagulants in patients with dilated cardiomyopathy. Thromb Haemost. 1985 Aug 30;54(2):521–523. [PubMed] [Google Scholar]
  26. La Rovere M. T., Pozzoli M., Traversi E., Opasich C., Specchia G. Exercise tolerance in patients with and without ventricular aneurysm. Cardiology. 1987;74(6):483–489. doi: 10.1159/000174242. [DOI] [PubMed] [Google Scholar]
  27. Lapeyre A. C., 3rd, Steele P. M., Kazmier F. J., Chesebro J. H., Vlietstra R. E., Fuster V. Systemic embolism in chronic left ventricular aneurysm: incidence and the role of anticoagulation. J Am Coll Cardiol. 1985 Sep;6(3):534–538. doi: 10.1016/s0735-1097(85)80109-1. [DOI] [PubMed] [Google Scholar]
  28. Levine M. N., Raskob G., Hirsh J. Hemorrhagic complications of long-term anticoagulant therapy. Chest. 1989 Feb;95(2 Suppl):26S–36S. doi: 10.1378/chest.95.2_supplement.26s. [DOI] [PubMed] [Google Scholar]
  29. Lip G. Y., Blann A. D. von Willebrand factor and its relevance to cardiovascular disorders. Br Heart J. 1995 Dec;74(6):580–583. doi: 10.1136/hrt.74.6.580. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Lip G. Y., Lowe G. D. Fibrin D-dimer: a useful clinical marker of thrombogenesis? Clin Sci (Lond) 1995 Sep;89(3):205–214. doi: 10.1042/cs0890205. [DOI] [PubMed] [Google Scholar]
  31. Lip G. Y., Lowe G. D., Metcalfe M. J., Rumley A., Dunn F. G. Effects of warfarin therapy on plasma fibrinogen, von Willebrand factor, and fibrin D-dimer in left ventricular dysfunction secondary to coronary artery disease with and without aneurysms. Am J Cardiol. 1995 Sep 1;76(7):453–458. doi: 10.1016/s0002-9149(99)80129-5. [DOI] [PubMed] [Google Scholar]
  32. Lip G. Y., Lowe G. D., Metcalfe M. J., Rumley A., Dunn F. G. Is diastolic dysfunction associated with thrombogenesis? A study of circulating markers of a prothrombotic state in patients with coronary artery disease. Int J Cardiol. 1995 Jun 2;50(1):31–42. doi: 10.1016/0167-5273(95)02327-s. [DOI] [PubMed] [Google Scholar]
  33. Lip G. Y., Lowe G. D., Rumley A., Dunn F. G. Increased markers of thrombogenesis in chronic atrial fibrillation: effects of warfarin treatment. Br Heart J. 1995 Jun;73(6):527–533. doi: 10.1136/hrt.73.6.527. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Lundström T., Rydén L. Haemorrhagic and thromboembolic complications in patients with atrial fibrillation on anticoagulant prophylaxis. J Intern Med. 1989 Feb;225(2):137–142. doi: 10.1111/j.1365-2796.1989.tb00053.x. [DOI] [PubMed] [Google Scholar]
  35. Maze S. S., Kotler M. N., Parry W. R. Flow characteristics in the dilated left ventricle with thrombus: qualitative and quantitative Doppler analysis. J Am Coll Cardiol. 1989 Mar 15;13(4):873–881. doi: 10.1016/0735-1097(89)90230-1. [DOI] [PubMed] [Google Scholar]
  36. Meltzer R. S., Visser C. A., Fuster V. Intracardiac thrombi and systemic embolization. Ann Intern Med. 1986 May;104(5):689–698. doi: 10.7326/0003-4819-104-5-689. [DOI] [PubMed] [Google Scholar]
  37. Mullen D. C., Posey L., Gabriel R., Singh H. M., Flemma R. J., Lepley D., Jr Prognostic considerations in the management of left ventricular aneurysms. Ann Thorac Surg. 1977 May;23(5):455–460. doi: 10.1016/s0003-4975(10)64166-5. [DOI] [PubMed] [Google Scholar]
  38. Nair C. K., Sketch M. H., Mahoney P. D., Lynch J. D., Mooss A. N., Kenney N. P. Detection of left ventricular thrombi by computerised tomography. A preliminary report. Br Heart J. 1981 May;45(5):535–541. doi: 10.1136/hrt.45.5.535. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Nixon J. V. Left ventricular mural thrombus. Arch Intern Med. 1983 Aug;143(8):1567–1571. [PubMed] [Google Scholar]
  40. Petersen P., Kastrup J., Vilhelmsen R., Schütten H. J. Atrial natriuretic peptide in atrial fibrillation before and after electrical cardioversion therapy. Eur Heart J. 1988 Jun;9(6):639–641. doi: 10.1093/oxfordjournals.eurheartj.a062554. [DOI] [PubMed] [Google Scholar]
  41. Reeder G. S., Lengyel M., Tajik A. J., Seward J. B., Smith H. C., Danielson G. K. Mural thrombus in left ventricular aneurysm: incidence, role of angiography, and relation between anticoagulation and embolization. Mayo Clin Proc. 1981 Feb;56(2):77–81. [PubMed] [Google Scholar]
  42. SCHLICHTER J., HELLERSTEIN H. K., KATZ L. N. Aneurysm of the heart: a correlative study of one hundred and two proved cases. Medicine (Baltimore) 1954 Feb;33(1):43–86. [PubMed] [Google Scholar]
  43. Saour J. N., Sieck J. O., Mamo L. A., Gallus A. S. Trial of different intensities of anticoagulation in patients with prosthetic heart valves. N Engl J Med. 1990 Feb 15;322(7):428–432. doi: 10.1056/NEJM199002153220703. [DOI] [PubMed] [Google Scholar]
  44. Sbarouni E., Bradshaw A., Andreotti F., Tuddenham E., Oakley C. M., Cleland J. G. Relationship between hemostatic abnormalities and neuroendocrine activity in heart failure. Am Heart J. 1994 Mar;127(3):607–612. doi: 10.1016/0002-8703(94)90670-x. [DOI] [PubMed] [Google Scholar]
  45. Sherman D. G., Dyken M. L., Fisher M., Harrison M. J., Hart R. G. Antithrombotic therapy for cerebrovascular disorders. Chest. 1989 Feb;95(2 Suppl):140S–155S. doi: 10.1378/chest.95.2_supplement.140s. [DOI] [PubMed] [Google Scholar]
  46. Simpson M. T., Oberman A., Kouchoukos N. T., Rogers W. J. Prevalence of mural thrombi and systemic embolization with left ventricular aneurysm. Effect of anticoagulation therapy. Chest. 1980 Apr;77(4):463–469. doi: 10.1378/chest.77.4.463. [DOI] [PubMed] [Google Scholar]
  47. Stratton J. R., Lighty G. W., Jr, Pearlman A. S., Ritchie J. L. Detection of left ventricular thrombus by two-dimensional echocardiography: sensitivity, specificity, and causes of uncertainty. Circulation. 1982 Jul;66(1):156–166. doi: 10.1161/01.cir.66.1.156. [DOI] [PubMed] [Google Scholar]
  48. Stratton J. R., Nemanich J. W., Johannessen K. A., Resnick A. D. Fate of left ventricular thrombi in patients with remote myocardial infarction or idiopathic cardiomyopathy. Circulation. 1988 Dec;78(6):1388–1393. doi: 10.1161/01.cir.78.6.1388. [DOI] [PubMed] [Google Scholar]
  49. Stratton J. R., Ritchie J. L. 111In platelet imaging of left ventricular thrombi. Predictive value for systemic emboli. Circulation. 1990 Apr;81(4):1182–1189. doi: 10.1161/01.cir.81.4.1182. [DOI] [PubMed] [Google Scholar]
  50. Tsevat J., Eckman M. H., McNutt R. A., Pauker S. G. Warfarin for dilated cardiomyopathy: a bloody tough pill to swallow? Med Decis Making. 1989 Jul-Sep;9(3):162–169. doi: 10.1177/0272989X8900900303. [DOI] [PubMed] [Google Scholar]
  51. Turpie A. G., Robinson J. G., Doyle D. J., Mulji A. S., Mishkel G. J., Sealey B. J., Cairns J. A., Skingley L., Hirsh J., Gent M. Comparison of high-dose with low-dose subcutaneous heparin to prevent left ventricular mural thrombosis in patients with acute transmural anterior myocardial infarction. N Engl J Med. 1989 Feb 9;320(6):352–357. doi: 10.1056/NEJM198902093200604. [DOI] [PubMed] [Google Scholar]
  52. Vandenberg B. F. 111In platelet scintigraphy and risk stratification for embolization from chronic left ventricular thrombi. Circulation. 1990 Apr;81(4):1419–1421. doi: 10.1161/01.cir.81.4.1419. [DOI] [PubMed] [Google Scholar]
  53. Visser C. A., Kan G., David G. K., Lie K. I., Durrer D. Two dimensional echocardiography in the diagnosis of left ventricular thrombus. A prospective study of 67 patients with anatomic validation. Chest. 1983 Feb;83(2):228–232. doi: 10.1378/chest.83.2.228. [DOI] [PubMed] [Google Scholar]
  54. Weinreich D. J., Burke J. F., Pauletto F. J. Left ventricular mural thrombi complicating acute myocardial infarction. Long-term follow-up with serial echocardiography. Ann Intern Med. 1984 Jun;100(6):789–794. doi: 10.7326/0003-4819-100-6-789. [DOI] [PubMed] [Google Scholar]
  55. Yamamoto K., Ikeda U., Furuhashi K., Irokawa M., Nakayama T., Shimada K. The coagulation system is activated in idiopathic cardiomyopathy. J Am Coll Cardiol. 1995 Jun;25(7):1634–1640. doi: 10.1016/0735-1097(95)00049-a. [DOI] [PubMed] [Google Scholar]

Articles from Postgraduate Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES