Future Research Regarding Anticoagulant Use in Reducing Recurrent Stroke: Alexander Merkler, MD, MS

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"These are secondary results, so it doesn’t mean that anticoagulation is definitely helpful. We need further studies and a dedicated trial to evaluate that hypothesis."

Exploratory data from the phase 3 NAVIGATE-ESUS trial (NCT02313909) provided evidence that rivaroxaban (Xarelto; Janssen), an anticoagulant, is superior to aspirin at reducing the risk of recurrent stroke or systemic embolism in patients with left ventricular dysfunction. The study included 7213 participants who had neuroimaging-confirmed embolic strokes of undetermined source (ESUS) between 7 days and 6 months before screening, 7107 (98.5%) of which had documented assessment of LV dysfunction at study entry and were included in the analysis.

Over a median follow-up of 10.4 months, the primary outcome of recurrent stroke or systemic embolism occurred in 321 participants (4.9% per year). When comparing the 2 treatments, event rates were 2.4% per year (95% CI, 1.1-5.4) in those assigned to rivaroxaban versus 6.5% (95% CI, 4.0-11) in those on aspirin. In those without LV dysfunction (n = 6605), event rates were similar between treatment arms, with event rates of 5.3% per year (95% CI, 4.5-6.2) for those on rivaroxaban and 4.5% per year on aspirin (95% CI, 3.8-5.3).

While these findings carry significant weight for the stroke community, the data needs to be replicated in larger scale trials. In an interview with NeurologyLive®, lead author Alexander Merkler, MD, MS, assistant professor of neurology, Weill Cornell Medicine, provided context on the long-term research projects he plans to carry out, as well as whether other anticoagulants may demonstrate similar results to rivaroxaban.

REFERENCE

Merkler AE, Pearce LA, Kasner SE, et al. Left ventricular dysfunction among patients with embolic stroke of undetermined source and the effect of rivaroxaban vs aspirin: a subgroup analysis of the NAVIGATE ESUS randomized clinical trial. JAMA Neurol. Published online October 25, 2021. doi:10.1001/jamaneurol.2021.3828