Reconsider antithrombotic therapy for embolic stroke of undetermined source (ESUS)

Abstract

Two large randomized clinical trials (NAVIGATE ESUS and RE-SPECT ESUS) to compare direct oral anticoagulants (DOACs) and aspirin in patients with embolic stroke of undetermined source (ESUS) did not show superiority of DOACs over aspirin for the prevention of recurrent stroke. These results suggest that covert atrial fibrillation is not a major player and arterial origin is more common than ever thought as a cause of embolism. Therefore, classification of causes into two groups by responding and non-responding to anticoagulation is required as much as possible for decision-making of antithrombotic therapy in ESUS patients. However, etiology is still unknown even after stroke recurrence in the majority of ESUS patients, and thereby, more extensive investigations and new approaches are mandatory. Regarding these issues, we reviewed and analyzed the results of NAVIGATE ESUS and RE-SPECTE EUS trials as well as their subgroup analyses, and described future perspectives.