A 58-year-old man undergoes primary PCI for an anterior STEMI. Transthoracic echocardiography on day 3 shows an apical left ventricular thrombus measuring 1.5 cm. His left ventricular ejection fraction is 35%. In addition to dual antiplatelet therapy, what is the most appropriate management?

• A Aspirin monotherapy indefinitely
• B Intravenous heparin for 72 hours only
• C Rivaroxaban 20 mg daily for life
• D Warfarin with target INR 2.0 to 3.0 for 3 to 6 months ✓

Explanation

Anterior STEMI with LV thrombus requires anticoagulation with warfarin (INR 2.0 to 3.0) for 3 to 6 months in addition to antiplatelet therapy, as per ESC guidelines. This reduces embolic risk. DOACs are not established for LV thrombus. Short-term heparin alone is insufficient to prevent embolization from an established mural thrombus.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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