BACKGROUND: Patients with cryptogenic stroke or embolic stroke of undetermined source (ESUS) face a high risk of recurrent ischaemic stroke, but the optimal antithrombotic strategy remains unclear. This systematic review and meta-analysis compared the effectiveness and safety of oral anticoagulants (OACs) versus antiplatelets in these populations, with a focus on subgroup effects by key clinical characteristics.
METHODS: Six databases were searched through March 2024 to identify randomised controlled trials (RCTs) comparing OACs and antiplatelets in patients with cryptogenic stroke or ESUS. The primary outcome was recurrent ischaemic stroke. Subgroup analyses evaluated treatment effects based on supracardiac atherosclerosis risk, presence of patent foramen ovale (PFO) and signs or risk factors for atrial cardiopathy. Meta-regression with interaction p values was employed to assess differences in treatment effects between subgroups.
RESULTS: Nine RCTs comprising 15 451 participants were included. In the overall population, there was no significant difference in recurrent ischaemic stroke risk between OACs and antiplatelets (relative risk (RR) 0.90, 95% CI 0.79 to 1.02; I2=0%). Subgroup analyses showed that OACs reduced ischaemic stroke risk in patients with low-risk supracardiac atherosclerosis (RR 0.53, 95% CI 0.35 to 0.80; I2=0%) compared with those with high-risk supracardiac atherosclerosis (RR 0.91, 95% CI 0.78 to 1.06; I2=0%) and evidence of supracardiac atherosclerosis (RR 1.13, 95% CI 0.84 to 1.53; I2=0%) (p interaction=0.0002). Similarly, OACs were more effective in patients with signs or risk factors for atrial cardiopathy (RR 0.84, 95% CI 0.70 to 0.99; I2=0%) than in those without atrial cardiopathy (RR 1.05, 95% CI 0.85 to 1.30; I2=0%) (p interaction=0.02). There was no significant interaction by PFO status (p interaction=0.28). While the risk of major bleeding risk was comparable between groups (RR 1.34, 95% CI 0.73 to 2.44; I2=65%), a significantly higher risk of major bleeding other than intracerebral haemorrhage was observed in patients taking OACs compared with antiplatelets (RR 1.69, 95% CI 1.18 to 2.43; I2=0%).
CONCLUSIONS: OACs are more effective than antiplatelets for preventing ischaemic stroke in patients who had a cryptogenic stroke or ESUS with low-risk supracardiac atherosclerosis or atrial cardiopathy. The findings highlight the need for personalised treatment strategies and further trials in these subgroups.
PROSPERO REGISTRATION NUMBER: CRD42024518903.
| Discipline Area | Score |
|---|---|
| Internal Medicine |  |
| Neurology |  |
his study attempts to untangle this issue using randomized control trials and a meta analysis; I do not think this question is ever going to be fully answered until a trial is designed specifically to answer this and collects enough of the data to truly determine both large vessel and cardiac risk simultaneously Embolic stroke of undetermined source and cryptogenic stroke are challenging conditions to treat. If the sources are in the carotids or higher, treating platelet-rich atheromas with dual antiplatelet therapy would make more sense than using anticoagulation. However, if atrial cardiomyopathy is the issue, with low flow and thrombus, then anticoagulation would be the best approach. This study addresses this issue using RCTs and a meta-analysis. I do not believe this question will ever be fully answered until a trial is specifically designed to address it and collects enough data to truly assess both large vessel and cardiac risks simultaneously.
As a geriatrician, I do not frequently encounter patients with this type of condition, as it is more typical in younger individuals. However, I find this information very useful in a general sense.
AI Translated: The optimal long-term antithrombotic strategy will depend on individualizing the benefit/risk of treatment in each patient. // La estrategia antitrombótica óptima a largo plazo dependerá de individualizar el beneficio/riesgo del tratamiento en cada paciente
