{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T23:41:20Z","timestamp":1787614880529,"version":"build-2736575974"},"reference-count":25,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T00:00:00Z","timestamp":1758844800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:p>Atrial fibrillation (AF) is the most common supraventricular arrhythmia and a major cause of stroke and systemic embolism. The left arial appendage (LAA) is the predominant site of thrombus formation in AF. According to current guidelines, oral anticoagulant (OAC) therapy is recommended in patients with elevated thromboembolic risk. Non-vitamin K antagonist oral anticoagulants (NOACs) are currently preferred over Vitamin K antagonists (VKAs) due to favorable safety profiles. Nevertheless, a subset of patients develop LAA thrombi despite optimal anticoagulant therapy, a clinical scenario not addressed by current guidelines. Recent retrospective studies, including our own cohort analysis, suggest, that modifying antithrombotic regimen may improve thrombus resolution in these cases. However, no prospective trials have yet defined the optimal strategy. This mini-review summarizes the available evidence, highlights the limitations of current practice, and proposes directions for future research in this underrecognized clinical dilemma.<\/jats:p>","DOI":"10.3389\/fcvm.2025.1664386","type":"journal-article","created":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T05:32:01Z","timestamp":1758864721000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Overcoming NOAC-resistant left atrial appendage thrombus in atrial fibrillation: clinical gaps and therapeutic insights"],"prefix":"10.3389","volume":"12","author":[{"given":"Klaudia Vivien","family":"Nagy","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bence","family":"Arn\u00f3th","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ferenc","family":"Koml\u00f3si","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"L\u00e1szl\u00f3","family":"Gell\u00e9r","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B\u00e9la","family":"Merkely","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,9,26]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"983","DOI":"10.1161\/01.STR.22.8.983","article-title":"Atrial fibrillation as an independent risk factor for stroke: the Framingham study","volume":"22","author":"Wolf","year":"1991","journal-title":"Stroke"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1633","DOI":"10.1093\/europace\/euz213","article-title":"Determinants of left atrium thrombi in scheduled cardioversion: an ENSURE-AF study analysis","volume":"21","author":"Merino","year":"2019","journal-title":"Europace"},{"key":"B3","doi-asserted-by":"publisher","first-page":"3554","DOI":"10.1161\/STROKEAHA.115.011273","article-title":"Left atrial appendage function and stroke risk","volume":"46","author":"Yaghi","year":"2015","journal-title":"Stroke"},{"key":"B4","doi-asserted-by":"publisher","first-page":"3314","DOI":"10.1093\/eurheartj\/ehae176","article-title":"2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European association for cardio-thoracic surgery (EACTS): developed by the task force for the management of atrial fibrillation of the European society of cardiology (ESC), with the special contribution of the European heart rhythm association (EHRA) of the ESC. 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