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Introduction Current guidelines recommend warfarin as the first-line treatment for left ventricular (LV) thrombus due to its well-established efficacy. However, emerging evidence indicates that direct oral anticoagulants (DOACs) may serve as potential alternatives.Aim To analyse trends in the utilization of warfarin and DOACs for the management of LV thrombus and evaluate their associated clinical outcomes.Methods Between January 2019 and December 2024, 85,800 echocardiograms were performed at a single-site, non-surgical cardiac centre in the UK. Reports were retrospectively reviewed to identify newly diagnosed LV thrombus, with patients stratified by clinician-selected anticoagulation (warfarin or DOACs).Results The study cohort of 189 patients were predominantly male, with a mean (±standard deviation) age of 66 ± 14 years. The mean LV ejection fraction (LVEF) at baseline was 35 ± 11%. The average thrombus diameter was 18 ± 10 mm. Anticoagulant therapy was given in 170 patients with 94 (49.7%) treated with warfarin, 70 (37%) with DOACs, and 6 (3.2%) low molecular weight heparin; 19 (10.1%) patients received no treatment. Among those receiving DOACs, Apixaban was most frequently prescribed (37.1%), followed by equal usage of Rivaroxaban and Edoxaban (30% in each group), and Dabigatran (2.9%). A switch from warfarin to DOACs was recorded in 30 patients (18.3%) which was primarily in those needing long term anticoagulant therapy. The use of DOACs to treat LV thrombus rose steadily from 2020, and in 2024, they were used more frequently than warfarin. ( Figure 1)Follow-up imaging demonstrated thrombus resolution in 79 patients (48.2%); with similar rates amongst those receiving warfarin (46/94, 48%) and DOACs (33/70, 47%), mean duration of 8 ± 7 months after the initiation of anticoagulation, with 62.5% of these patients continuing long-term anticoagulant therapy.Similar demographic characteristics and comorbidity profiles was noted between warfarin and DOAC groups. Thrombus size did not differ significantly between groups; however, the mean LVEF was lower in the warfarin versus DOAC group (33 ± 10% versus 37 ± 9%, p = 0.014). Patients treated with DOAC had shorter time to thrombus resolution on follow up scan. (Table 1)Over a mean follow-up period of 29 ± 20 months, 55 patients (33.5%) experienced the composite primary outcome—which encompassed 17 cerebrovascular events, 1 other thromboembolic event, 1 major bleeding, 36 all-cause deaths of which 6 were cardiovascular-related. More clinical events were noted in the warfarin group (40.4% vs 24.3%, p=.044). (Figure 2) Demographic characteristics, comorbidities, LVEF, thrombus size, and treatment modality did not have a significant impact on clinical outcomes in patients with LV thrombus. Of note, patients treated with warfarin exhibited a 2.4 times increased risk of experiencing a primary outcome event (HR 2.4, CI 1.097–5.298, p=.029) (table 2)Conclusion Our study indicates a shifting trend towards the use of DOACs for LV thrombus management, with comparable efficacy and safety to warfarin. Furthermore, our findings suggest more favourable clinical outcomes in patients treated with DOACs. However, given the retrospective nature of our analysis, randomized controlled trials are needed to definitively establish the role of DOACs in this clinical setting.Abstract 5-026 Figure 1Patterns of warfarin and direct oral anticoagulant (DOAC) utilizationAbstract 5-026 Table 1Demographic characteristics, comorbidities, echocardiographic findings and clinical outcomes between Warfarin and DOAC groups Warfarin (n=94) DOAC (n=70) p value Age (years) 65±15 67±12 .336 Sex (male) (N, %) 75 (79.8) 59 (84.3) .543 Coronary artery disease (N, %) 71 (75.5) 48 (68.6) .378 Hypertension (N, %) 33 (35.1) 29 (41.4) .421 Type 2 diabetes (N, %) 35 (37.2) 17 (24.3) .091 Chronic kidney disease (N, %) 35 (37.2) 22 (31.4) .508 Atrial fibrillation (N, %) 15 (16.0) 24 (34.3) .009 Dyslipidaemia (%) 25 (26.6) 26 (37.1) .174 Baseline LVEF (%) 33 ± 10 37 ± 9 .014 Thrombus diameter (mm) 19 ± 10 17 ± 11 .259 Time to thrombus resolution on follow up scan (months) 9 ±9 5 ± 5 .031 Number of patients with thrombus resolution 46 33 .446 Clinical event (N, %)1. Stroke2. Other thromboembolic3. Major bleeding4. All-cause mortality 38 (40.4)9 (9.6)1 (1.1)1 (1.1)27 (28.6) 17 (24.3)8 (11.4)009 (12.9) .044 Abstract 5-026 Figure 2Kaplan-meier survival curve stratified by treatment groupsAbstract 5-026 Table 2The impact of demographic characteristics, comorbidities, LV function, size of thrombus and treatment on the incidence of clinical outcome HR (95% CI) P value Age 1.029 (.998–1.060) .065 Sex (male) 1.227 (.472–3.187) .675 Coronary artery disease 1.563 (.646- 3.78) .322 Hypertension 1.131(.533–2.401) .749 Type 2 diabetes .766 (.336–1.743) .525 Chronic kidney disease .716 (.314–1.636) .429 Atrial fibrillation .720 (.301–1.723) .461 Dyslipidaemia 1.228 (.539–2.797) .625 LVEF .986 (.951–1.023) .460 Size of thrombus .985 (.947 -1.024) .441 Warfarin 2.410 (1.097–5.298) .029