ISC 2024 | Debate on ESUS standard of care: exploring alternatives in stroke management

Ashkan Shoamanesh, MD, McMaster University, Population Health Research Institute, Hamilton, ON, Canada, discusses a debate which took place at the International Stroke Conference 2024 on the standard of care for patients with embolic stroke of undetermined source (ESUS). The debate arises from four negative trials comparing anticoagulation with antiplatelet therapy in ESUS patients, namely NAVIGATE ESUS (NCT02313909), RE-SPECT ESUS (NCT0223912), ATTICUS (NCT02427126), and ARCADIA (NCT03192215). Dr Shoamanesh challenges the notion that ESUS is an invalid construct, citing evidence that a heterogeneous ESUS population has been shown to respond well in various trials of dual antiplatelet therapy. This suggests the treatments tested in the negative anticoagulation trials have been the problem and not the construct itself. Dr Shoamanesh advocates for continued research on ESUS subtypes, such as those with left ventricular dysfunction and active malignancy. He emphasizes ongoing trials, like OCEANIC-STROKE (NCT05686070), investigating FXI inhibitors in ESUS patients enriched with atherosclerotic disease. This interview took place at the International Stroke Conference 2024 in Phoenix, AZ.

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