Name:
Prevention after ESUS
Description:
Prevention after ESUS
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Duration:
T00H04M55S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
>> Practice Impact Extra podcasts are derived from Hurst's the Heart Board Review and other online resources available only through accesscardiology.com. >> Cryptogenic stroke is responsible for so many ischemic strokes. What trials do we have now that will afford us an opportunity to assess prevention of further strokes?
Hi, I'm Dr. Bernie, and welcome again to Practice Impact Extra. In 2014, the definition of embolic strokes of undetermined origin and source, ESUS, E-S-U-S, emerged as a new clinical construct to characterize cryptogenic stroke. Cryptogenic strokes constitute 20% to 30% of ischemic strokes, and most were presumed to be embolic or of undetermined source.
I'd like to take an opportunity to review two randomized trials that assess the risk of recurrent ischemic stroke, comparing aspirin as an antiplatelet therapy to the NOAC rivaroxaban and the dabigatran. The first trial was the NAVIGATE-ESUS trial, and this was published in the New England Journal of Medicine in 2018. This trial enrolled 7213 people with a recent ischemic stroke presumed to be from a cerebral embolic event, but without any arterial stenosis, it was not a lacunar infarct, and there was no identifiable cardioembolic source.
So, what was the primary outcome? The primary outcome they were measuring was the first recurrence of ischemic stroke or systemic embolism and also combined with the safety outcome, particularly as it related to the rate of major bleeding. The trial, however, was terminated early at 11 months. The trial was a negative trial. It found no significant difference between rivaroxaban or aspirin in the number of recurrent strokes by 4.8% versus 5.1%. The primary outcome of bleeding, however, did find a significant increase in bleeding events, and that led to the early termination of that study.
The second trial I wanted to present was the RESPECT-ESUS trial, and this also was published in the New England Journal in 2019. This trial randomized 5300 patients to dabigatran or aspirin in patients with ESUS. The primary outcome was recurrent ischemic stroke again, as well as major bleeding. The results at 19 months demonstrated no significant difference in recurrent ischemic stroke between the dabigatran and aspirin group, 4.1% versus 4.8%. Major bleeding was similar in both groups, but more patients in the dabigatran group than in the aspirin group had clinically relevant non-major bleeding.
So, really what's the take-home message? These two randomized clinical trials suggest that indiscriminate anticoagulation treatment with NOAC, in this case rivaroxaban and the dabigatran, is neither effective nor safe for patients with symbolic stroke of undetermined source, the ESUS group. I think these studies emphasize the importance that you need to do a complete comprehensive diagnostic workup to assist in uncovering occult causes of embolic stroke of undetermined sources.
I call attention to two trials that are continuing in the ESUS group, looking at apixaban, and we'll wait for the future results to shed more light on the use of NOAC, particularly apixaban, in the future for treatment of ESUS. Again, thank you for joining me, and see you next time on Practice Impact Extra. >> We hope you enjoyed this podcast from McGraw-Hill.
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