Meta-Analysis of Recent Clinical Trials on Prevention of Stroke After Embolic Strokes of Undetermined Source
Muhammad Ahmed1, Hafiz Maaz2, Muhammad Tayyab Muzaffar Chaychi3, Muhammad Sohaib4
1Medical College of Georgia, Augusta University, 2Quaid-e-Azam Medical College, Bahawalpur Pakistan, 3Resident Physician, Department of Neurology, University of South Florida Morsani College of Medicine, 4Rollins School of Public Health, Emory University, Atlanta
Objective:

This meta-analysis compared the efficacy and safety of anticoagulation (AC) and antiplatelet therapies in preventing recurrent stroke after ESUS.

Background:
Embolic strokes of undetermined source (ESUS) account for a significant proportion of strokes, carrying a high risk of recurrence. Recent clinical trials have evaluated various interventions for secondary prevention in this population.
Design/Methods:

A systematic search of electronic databases and conference proceedings identified randomized controlled trials comparing anticoagulation and antiplatelet therapies in adult ESUS patients. The primary outcome was the composite of ischemic stroke and major bleeding. Secondary outcomes included recurrent stroke, mortality, and bleeding complications.

Results:

Four trials with a total of 13,970 patients (6,989 AC, 6,981 antiplatelet), were included. The primary outcome occurred in 7.22% of antiplatelet patients and 1.59% of anticoagulation patients (RR 1.04, 95% CI: 0.88-1.24, p=0.63). Recurrent stroke or ischemic embolism rates were 6.04% (antiplatelet) and 5.65% (anticoagulation) (RR 0.94, 95% CI 0.77-1.13, p=0.49). Mortality rates were 1.75% (antiplatelet) and 1.95% (anticoagulation) (RR 1.11, 95% CI: 0.87-1.42, p=0.63). Major bleeding occurred in 1.43% (antiplatelet) and 2.13% (anticoagulation) (RR 1.24, 95% CI 0.59-2.59, p=0.58). Clinically relevant non-major bleeding was significantly higher with antiplatelet therapy (RR 1.52, 95% CI 1.20-1.50, p=0.0006).

Conclusions:
Anticoagulation and antiplatelet therapies are equally effective in preventing recurrent stroke after ESUS. However, anticoagulation is associated with a higher risk of major bleeding. This meta-analysis indicates that anticoagulation with DOAC does not provide additional secondary prevention benefits in ESUS patients.
10.1212/WNL.0000000000212233
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