Anticoagulation in ESUS with Atrial Cardiopathy

Core Concepts

Apixaban does not offer benefits over aspirin in ESUS patients with atrial cardiopathy.

Abstract

The ARCADIA trial compared apixaban to aspirin in ESUS patients with atrial cardiopathy, finding no improvement in recurrent stroke rates or safety outcomes. The study presenter highlighted the lack of benefit of apixaban over aspirin in this patient population. Secondary analyses will be conducted to explore potential explanations. Similar results were seen in previous ESUS trials. The definition of atrial cardiopathy and the heterogeneity of patients were discussed. The failure of anticoagulation in previous trials led to the hypothesis of different underlying etiologies requiring varied antithrombotic therapy. The trial methodology, patient characteristics, outcomes, and safety results were detailed. Twitter reactions from experts were also included.

Stats

The primary efficacy outcome of recurrent stroke of any type occurred in 4.4% of patients treated with apixaban and those given aspirin.
Rates of major hemorrhage were low and almost identical between the groups.
Proportionately more patients treated with aspirin experienced symptomatic intracranial hemorrhage.

Quotes

"It could be that this concept of thrombogenic atrial cardiopathy really isn't present unless there is also atrial fibrillation." - Hooman Kamel, MD, MS

Key Insights Distilled From

Cardiopathy No Basis for Choosing Anticoagulation in ESUS

by Liam Davenpo... at www.medscape.com 05-29-2023

https://www.medscape.com/viewarticle/992525

Deeper Inquiries

What other biomarkers could be considered in future studies to assess atrial cardiopathy?

In future studies assessing atrial cardiopathy, additional biomarkers could be considered to provide a more comprehensive evaluation. Some potential biomarkers that could be explored include markers of inflammation such as C-reactive protein (CRP) or interleukins, markers of myocardial strain like troponin or myoglobin, markers of fibrosis such as galectin-3 or procollagen type I carboxy-terminal peptide, and markers of endothelial dysfunction like von Willebrand factor or endothelin-1. These biomarkers may offer insights into different aspects of atrial cardiopathy, helping to refine patient selection criteria and improve treatment strategies.

Is there a potential benefit in subgroup analyses for patients with specific characteristics?

Subgroup analyses for patients with specific characteristics can be highly beneficial in clinical trials, especially in complex conditions like embolic stroke of undetermined source (ESUS) with atrial cardiopathy. By conducting subgroup analyses, researchers can identify potential differences in treatment effects based on patient characteristics such as age, sex, comorbidities, or biomarker levels. This approach allows for a more personalized and targeted treatment strategy, potentially uncovering subgroups of patients who may benefit more from a particular intervention. In the context of the ARCADIA trial, subgroup analyses could help elucidate whether certain patient subgroups with atrial cardiopathy may respond differently to anticoagulation therapy, guiding future clinical decision-making.

Should all patients with low AF burden or incidental AF after stroke be anticoagulated?

The decision to anticoagulate all patients with low atrial fibrillation (AF) burden or incidental AF after stroke is a complex clinical dilemma that requires careful consideration. While anticoagulation therapy has shown benefits in preventing strokes in patients with AF, the optimal management of patients with low AF burden or incidental AF remains uncertain. Individualized risk assessment, weighing the potential benefits of anticoagulation against the risks of bleeding, is crucial in determining the appropriate treatment approach for these patients. Factors such as age, comorbidities, stroke etiology, and bleeding risk should be taken into account when making treatment decisions. Further research and clinical guidelines are needed to provide clear recommendations on anticoagulation in patients with low AF burden or incidental AF after stroke.