ESOC 2022 | ATTICUS trial of apixaban vs aspirin for secondary prevention after ESUS: findings & implications

Sven Poli, MD, & Tobias Geisler, MD, Eberhard-Karls University of Tübingen, Tübingen, Germany, present the prospective, randomized, controlled ATTICUS trial (NCT02427126), assessing apixaban versus aspirin for secondary prevention after embolic stroke of undetermined source (ESUS). Two previous trials (NAVIGATE ESUS; NCT02313909 and RE-SPECT ESUS; NCT02239120) have assessed direct oral anticoagulation for secondary prevention in the ESUS population, with neutral or negative outcomes. Differing from these studies, ATTICUS enrolled patients with a risk factor profile for cardiac thromboembolism to enrich the population for atrial fibrillation (AF), as well as conducting mandatory continuous cardiac monitoring and shortening the time from index stroke to randomization. The trial was ended due to futility based on the findings of the interim analysis. The final analysis of 373 patients showed no significant difference in the primary endpoint of any new ischemic lesion detected on MRI between the apixaban and aspirin arms. Continuous cardiac monitoring detected AF in over 25% of the study population. All patients found to have AF in the aspirin arm were switched to receive apixaban, which may have contributed to the neutral result. In those that did not show AF, aspirin and apixaban were equally potent in preventing new ischemic lesions. Overall, ATTICUS showed that both approaches can be used and that early initiation of apixaban after ESUS appeared safe, with only an increase in minor bleeding events compared to aspirin use. This interview took place at the ESOC 2022 congress in Lyon, France.