Mural thrombus following myocardial infarction

If left ventricular mural thrombus is demonstrated by echocardiography or other imaging (eg cardiac magnetic resonance imaging), anticoagulation is essential unless there is a clinical contraindication.

Warfarin is the recommended oral anticoagulant for left ventricular mural thrombus; direct-acting oral anticoagulants (DOACs) have not been well studied for this indication. A parenteral anticoagulant (a low molecular weight heparin [LMWH] [eg enoxaparin, dalteparin] or unfractionated heparin [UFH]) must be given initially to overcome the delay in achieving therapeutic anticoagulation and the initial increase in prothrombotic potential associated with starting warfarin.

Start warfarin on the same day as the parenteral anticoagulant, following the hospital protocol for determining the warfarin dose. If a local protocol is not available, use:

Monitor international normalised ratio (INR) daily and adjust the warfarin dose until the target INR is reached. See Practical information on using warfarin for information about dosing, monitoring and management of bleeding and overanticoagulation.

Warfarin therapy is usually used for 3 months or until left ventricular mural thrombus has resolved; however, the need for ongoing anticoagulation and its duration should be guided by the specialist.

Give a parenteral anticoagulant with warfarin until the INR has been above 2 on two consecutive days, then stop the parenteral anticoagulant and continue warfarin alone.

Suitable regimens of LMWH for mural thrombus following myocardial infarction are:

If dalteparin is required for a patient with a calculated creatinine clearance (CrCl) less than 30 mL/min, seek expert advice. For information about enoxaparin and dalteparin, such as determinants of bleeding and management of bleeding, see Practical information on using low molecular weight heparin. See also considerations for anticoagulation in obese patients if applicable.

Unfractionated heparin is used for patients with severe kidney impairment or who have a high risk of active bleeding that may require rapid reversal of anticoagulation (see Practical information on using unfractionated heparin for information, such as management of bleeding). Dose according to the local hospital protocol for acute coronary syndromes. If a local hospital protocol is not available, a suitable starting dose for mural thrombus following myocardial infarction is: