Triple Antithrombotic Therapy for the Prevention of Left Ventricular Thrombus Following Anterior ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis.

Abstract

Left ventricular thrombus (LVT) is a serious complication of anterior ST-elevation myocardial infarction (STEMI). Despite guideline endorsement of prophylactic anticoagulation in selected high-risk patients, the supporting evidence remains of low certainty. Aim of our systematic review and meta-analysis is to evaluate the efficacy and safety of triple antithrombotic treatment (TAT) versus dual antiplatelet treatment (DAPT) alone for LVT prevention in patients with anterior STEMI treated with primary percutaneous coronary intervention (pPCI). Three electronic databases (EMBASE, MEDLINE, Cochrane Library) were systematically searched from inception to February 2026, following PRISMA 2020 guidelines. Eligible studies enrolled adult patients with anterior STEMI revascularised by pPCI, compared prophylactic TAT with DAPT alone, and reported LVT outcomes. Data were pooled as risk ratios (RR) with 95% confidence intervals (CI) using random-effects models. The primary outcome was LVT formation; secondary outcomes were major bleeding and systemic embolism. Six studies including 2,021 patients were analyzed. Pooled analysis demonstrated no statistically significant reduction in LVT formation with TAT (RR 0.54, 95% CI 0.21-1.40; p=0.21; I2=61%), whereas major bleeding risk was significantly increased (RR 2.69, 95% CI 1.40-5.19; p=0.003; I2=14%). A non-significant trend toward reduced systemic embolism was observed (RR 0.44, 95% CI 0.18-1.07; p=0.07; I2=0%). The addition of prophylactic anticoagulation to DAPT in patients with anterior STEMI treated with pPCI does not show a statistically significant reduction in LVT formation while significantly increasing major bleeding risk. These findings do not support routine prophylactic TAT in unselected patients with anterior STEMI.