*7.2. Suggested Algorithm*

In medically managed patients, a dual therapy is preferred in order to curtail the bleeding risk while patients undergoing PCI will need an initial triple therapy regimen (DAPT+OAC). For one of our patients, we prescribed dual therapy with VKAs, while for another patient, we gave dual therapy with DOACs. Interestingly, both patients responded well to dual therapy, and there was a resolution of the LV thrombus at 1 month. More importantly, there were no thromboembolic events; neither were there any bleeding episodes. Certain clinical features that predict a high risk of stroke, such as a prior systemic embolism, the protrusion of a thrombus into the cavity, a recurrent thrombus, and the nonresolution of a thrombus from the initial therapy, may call for the preferential use of warfarin-based anticoagulation [10,34]. Patients with a high risk of stent thrombosis (recurrent ACS, multiple stents, complex bifurcation PCI, heavily calcified lesions, total stent length >60 mm, or bioabsorbable stents) may benefit from the extended duration of initial triple therapy [57].

A suggested algorithm regarding the choice and duration of anticoagulation use in LV thrombi that is based on the current literature is presented in Figure 4.

Nonetheless, the lack of a predictable anticoagulant response, narrow therapeutic range, and need for frequent monitoring has spurred the more widespread use of DOACs and use of DOAC-based combination therapy in AMI patients who require concomitant oral anticoagulation. Because rivaroxaban and apixaban are now off patent, the financial constraints may no longer be a valid argument in many geographical regions, leading to increased prescriptions. However, as previously detailed, there is no need to jump the queue in utilizing DOACs until their noninferiority is established in large RCTs, and they should still be alternatives to VKAs on case-by-case bases.
