LV Thrombus Post-MI — EECC MCQ

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ModerateCoronary Artery DiseaseLV Thrombus Post-MIEECC

A 55-year-old man with prior inferior MI is found to have a moderate-sized LV apical thrombus on echocardiography. He is 3 weeks post-MI and on aspirin 75 mg, ticagrelor 90 mg bd, and atorvastatin 80 mg. What additional treatment is recommended?

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Correct answer: D — Therapeutic anticoagulation with interval imaging

LV thrombus post-MI requires therapeutic anticoagulation to prevent systemic embolisation (particularly stroke). The recommended approach is warfarin (INR 2.0-3.0) for at least 3-6 months, with serial imaging (echo or CMR) to confirm thrombus resolution. When added to DAPT, this creates triple antithrombotic therapy (TAT), which carries significant bleeding risk. The 2023 ESC ACS Guidelines recommend minimising the duration of TAT: aspirin may be dropped early (within 1 week), continuing with a DOAC or warfarin plus a P2Y12 inhibitor. Some centres use DOACs (apixaban or rivaroxaban) instead of warfarin for LV thrombus, though evidence is from observational studies. Repeat imaging at 3 months guides anticoagulation duration.

Reference: ESC (2023): Guidelines for the Management of Acute Coronary Syndromes: https://www.nice.org.uk/guidance/ng238/chapter/recommendations