Author + information
- Received August 30, 2019
- Revision received October 8, 2019
- Accepted November 3, 2019
- Published online January 20, 2020.
- George Ntaios, MD, MSc, PhD∗ ()
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- ↵∗Address for correspondence:
Dr. George Ntaios, Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Thessaly 41110, Greece.
• Covert atrial fibrillation seems to be less important as an ESUS etiology than was initially conceived.
• Potential embolic sources overlap considerably in ESUS, which may explain the neutral trial results.
• Ongoing research investigates ESUS subgroups that may respond better to anticoagulation.
• Combining anticoagulant with antiplatelet warrants further research in ESUS with atherosclerosis.
The term embolic stroke of undetermined source (ESUS) was introduced in 2014 to describe patients with a nonlacunar ischemic stroke and no convincing etiology. The terms ESUS and cryptogenic stroke are not synonyms, as the latter also includes patients with multiple stroke etiologies or incomplete diagnostic work-up. ESUS involves approximately 17% of all ischemic stroke patients, and these patients are typically younger with mild strokes and an annual rate of stroke recurrence of 4% to 5%. It was hypothesized that oral anticoagulation may decrease the risk of stroke recurrence in ESUS, which was tested in 2 large randomized controlled trials: the NAVIGATE ESUS (Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source) and the RE-SPECT ESUS (Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source). The present review discusses the trials of anticoagulation in patients with ESUS, suggests potential explanations for their neutral results, and highlights the rationale that supports ongoing and future research in this population aiming to reduce the associated risk for stroke recurrence.
- atherosclerotic plaques
- embolic stroke of undetermined source
- oral anticoagulation
- patent foramen ovale
Dr. Ntaios has received speaker fees from, served on advisory boards for, or received research support from Amgen, Bayer, Bristol-Myers Squibb/Pfizer, Boehringer Ingelheim, and Elpen outside of the submitted work.
- Received August 30, 2019.
- Revision received October 8, 2019.
- Accepted November 3, 2019.
- 2020 American College of Cardiology Foundation
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