Direct Oral Anticoagulants for Prevention of lEft ventRIcular Thrombus After Anterior Acute Myocardial InFarction - APERITIF

Inclusion Criteria:

• Age ≥ 18 years;

• Anterior STEMI (e.g., ST elevation above the J-point of ≥0.1 millivolt in ≥twocontiguous leads or left bundle branch block) or very high-risk NSTEMI (e.g.,dynamic ECG changes or ongoing chest pain or acute heart failure or hemodynamicinstability independent of ECG changes or life-threatening ventricular arrhythmias)with echographic evidence of anterior wall motion abnormalities and, with a culpritlesion of the proximal or mid portion of the left anterior descending (LAD) on thecoronary angiography;

• No contraindication to CMR (e.g., claustrophobia, pacemaker or defibrillator notcompatible);

• Ability to provide written informed consent and willing to participate in 1-monthfollow-up period.

• Affiliation of social security regime.

Exclusion Criteria:

• Patients with cardiogenic shock (systolic blood pressure <90 mmHg with clinicalsigns of low output or patients requiring inotropic agents);

• Patients referred to surgery for coronary artery bypass grafting (CABG) or treatmentof acute complications (e.g. ventricular septal rupture);

• Patients treated with fibrinolytic therapy;

• LV thrombus diagnosed before randomization using a transthoracic echocardiography;

• Active major bleeding or major surgery within the last 30 days;High bleeding risk (patients considered at increased risk of bleeding during DAPT; e.g. PRECISE-DAPTscore >25; severe liver failure or Child Pugh class C);

• Known history of intracranial hemorrhagic stroke or intra-cranial aneurysm;

• Known history of peptic ulcer;

• Known stroke (any type) within the last 30 days;

• Known intolerance to aspirin, P2Y12 inhibitors, rivaroxaban and their excipients;

• Patients with presence of malignant neoplasms at high risk of bleeding

• Patients with hepatic impairment

• According to the SmPC any contraindication to rivaroxaban, aspirin, clopidogrel,ticagrelor

• Known intolerance to gadolinium chelates;

• Chronic kidney disease (creatinine clearance (ClCr) <30 mL/min);

• Indication for anticoagulation (e.g. atrial fibrillation, mechanical valves, LVthrombus...);

• Life expectancy <1 month;

• Known pregnancy at time of randomization (pregnancy test done) or breastfeedingwomen;

• Currently participating in another trial

• Protected adults (including individual under guardianship by court order)

• Persons deprived of their liberty by judicial or administrative decision