ISC 2023 | Direct oral anticoagulation versus aspirin after ESUS: next investigational steps

Subgroup analyses as part of the ATTICUS trial (NCT02427126) have suggested that the use of apixaban after embolic stroke of undetermined source (ESUS) may be superior to acetylsalicylic acid (ASA) for secondary prevention in elderly patients. It was demonstrated that patients aged 75 or over showed a trend towards benefit with apixaban when assessing a composite endpoint of recurrent stroke, myocardial infarction, and cardiovascular death. Sven Poli, MD, MSc, FESO, FWSO, FAHA, Eberhard-Karls University of Tübingen, Tübingen, Germany, comments on the relevance of these findings moving forward. These findings are in line with data from the RE-SPECT ESUS trial, which found a lower rate of recurrent stroke with dabigatran use versus ASA in the subgroup aged ≥75 years. The ATTICUS results build on this, showing that elderly participants in the apixaban arm performed better than those receiving ASA, as well as those who switched to apixaban from ASA following AF detection. Dr Poli notes that pooling the data from all three trials assessing direct oral anticoagulation for secondary prevention in the ESUS population may shed more light on this patient subgroup. This interview took place during the International Stroke Conference (ISC) 2023 in Dallas, TX.

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