Add on DAPT to Rivaroxaban Fails to Reduce Left Ventricular Thrombus Formation After Anterior STEMI: Study
France: Researchers have found in a new multicenter randomized clinical trial of patients with anterior STEMI that the addition of low-dose rivaroxaban to dual antiplatelet therapy (DAPT) did not significantly reduce left ventricular thrombus formation at 1 month, while it was associated with an increase in minor bleeding. Due to the study’s limited statistical power, the results should be interpreted cautiously, and a modest therapeutic benefit cannot be ruled out.
The findings from the APERITIF trial were published in JAMA Cardiology by Etienne Puymirat of the Department of Cardiology, Hôpital Européen Georges-Pompidou, Assistance Publique–Hôpitaux de Paris (AP-HP), France, and colleagues. The investigators examined whether adding low-dose rivaroxaban to standard DAPT could help prevent left ventricular (LV) thrombus in patients experiencing anterior ST-segment elevation myocardial infarction (STEMI), a population known to carry elevated thrombotic risk.
Anterior myocardial infarction is strongly associated with impaired ventricular function and thrombus formation, potentially leading to systemic embolic events. While oral anticoagulants may theoretically lower this risk, combining them with antiplatelet agents increases bleeding concerns. To explore this balance, the researchers conducted a multicenter, open-label, blinded endpoint trial across 29 centers in France. The study was embedded within the FRENCHIE registry and enrolled patients between October 2021 and January 2023.
A total of 560 patients with anterior STEMI were randomized shortly after coronary intervention to receive either DAPT plus rivaroxaban 2.5 mg twice daily for four weeks (283 patients) or DAPT alone (277 patients). The primary outcome was the presence of LV thrombus detected by contrast-enhanced cardiac magnetic resonance imaging at one month.
The following findings were reported:
- Left ventricular thrombus at one month was detected in 13.7% of patients receiving rivaroxaban plus DAPT and 16.6% of those receiving DAPT alone, with no statistically significant difference between the groups.
- There were no significant differences in the size of the thrombus between the two treatment arms.
- The incidence of major adverse cardiovascular events was similar in both groups.
- Major bleeding events were infrequent and occurred at comparable rates in the two groups.
- Minor bleeding episodes were more common in patients treated with rivaroxaban in addition to DAPT.
The study had limitations, including its open-label design and lower-than-expected event rates, which reduced statistical power. As a result, a small benefit or harm cannot be excluded. The trial was not powered to detect differences in clinical events.
In summary, the APERITIF trial suggests that routine addition of low-dose rivaroxaban to DAPT after anterior STEMI does not significantly lower the risk of LV thrombus at one month and increases minor bleeding. Further research would be needed to clarify whether selected high-risk patients might derive benefit from such an approach.
Reference:
Puymirat E, Soulat G, Lattuca B, et al. Low-Dose Rivaroxaban to Prevent Left Ventricular Thrombosis After Anterior Myocardial Infarction: The APERITIF Randomized Clinical Trial. JAMA Cardiol. Published online February 25, 2026. doi:10.1001/jamacardio.2026.0026
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