ISC 2026 | Individual patient data meta-analysis of anticoagulant versus aspirin after an ESUS

So there were four trials. They were comparing anticoagulant versus aspirin in patients after ESUS. And as we all know, those trials were neutral. So they didn’t prove that anticoagulation is superior to aspirin. So interestingly enough, there were many publications after those four trials looking at subgroups. And some of them suggested a possible benefit of anticoagulation over aspirin in some of those subgroups. But unfortunately, up until today, those results have not been replicated across trials. Some of them, they were presented as positive in one trial and were presented as neutral in another trial. So what we did do is we did an individual patient data meta-analysis. So we gathered individual patient data from all four trials, and that’s NAVIGATE ESUS, RE-SPECT ESUS, ARCADIA, and ATTICUS. And we analyzed them all together with a specific focus on subgroups. So what came up from this individual patient meta-analysis is that first, we didn’t find that anticoagulation reduces the risk of recurrent stroke compared to aspirin in patients after an ESUS. Also, it does not increase the bleeding, although there was some heterogeneity for the second part in some of the trials. They reported higher bleeding rates compared to others, you know, of course, comparison was as well as aspirin. Importantly, what we did, we looked at subgroups so we looked at subgroups unadjusted so you know as they were provided within the trials but we also adjusted for predefined confounders. And interestingly although we looked at multiple subgroups based on patients’ characteristics, imaging characteristics or echocardiographic characteristics we’re not able to identify a single subgroup that seems to benefit from anticoagulation compared to aspirin after an ESUS.

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