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ESUS: Embolic Strokes of Undetermined Source Not so cryptogenic anymore?

ESUS: Embolic Strokes of Undetermined Source Not so cryptogenic anymore?. George Ntaios University of Thessaly, Larissa , Greece. European PFO Summit Zurich, 16/10/2015. Disclosures. Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis.

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ESUS: Embolic Strokes of Undetermined Source Not so cryptogenic anymore?

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  1. ESUS: Embolic Strokes of Undetermined Source Not so cryptogenic anymore? George Ntaios University of Thessaly, Larissa, Greece European PFO Summit Zurich, 16/10/2015

  2. Disclosures Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. Honoraria: Medtronic; Quintiles; Boehringer-Ingelheim. Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Elpen; Bayer Support to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica;Elpen; Bristol Myers Squibb. Participation in trials: • NAVIGATE-ESUS / National Coordinator (Greece) • GLORIA-AF / Sub-investigator (Larissa). • FOURIER / Principal investigator (Larissa). • ENOS / National Coordinator (Greece). • EBBINGHAUS / Principal Investigator (Larissa). • PRECIOUS / National Coordinator (Greece). • BIOSIGNAL / Principal Investigator (Larissa). • PREVISE / Principal investigator (Larissa).

  3. Cryptogenic stroke: not rare

  4. Cryptogenic stroke: not innocent Ntaios et al. EurJ Neurol. 2014; 21:1108-14

  5. TOAST classification ?

  6. ESUS: Embolic Strokes of Undetermined Source Hart et al. Lancet Neurol 2014; 13: 429–38

  7. Cryptogenic stroke: what actually do you mean? Cryptogenic Not investigated Multiple causes Really cryptogenic

  8. ESUS: diagnostic criteria • Stroke detected by CT or MRI that is not lacunar. • Absence of extracranial or intracranial atherosclerosis causing >50% luminal stenosis in arteries supplying the area of ischemia. • No major-risk cardioembolic source of embolism(permanent or paroxysmal AF, sustained atrial flutter, intracardiac thrombus, prosthetic cardiac valve, atrial myxoma or other cardiac tumours, mitral stenosis, recent (<4 weeks) MI, LVEF<30%, valvularvegetations, or infective endocarditis). • No other specific cause of stroke identified. Hart et al. Lancet Neurol 2014; 13: 429–38

  9. ESUS: potential causes Hart et al. Lancet Neurol 2014; 13: 429–38

  10. ESUS: diagnostic algorithm • Brain CT or MRI • 12-lead ECG • Precordial echocardiography • Imaging of both extra- and intracranial arteries supplying the area of brain ischemia • Cardiac monitoring for ≥24hours with automated rhythm detection Hart et al. Lancet Neurol 2014; 13: 429–38

  11. CRYSTAL-AF Sanna et al. N Engl J Med 2014;370:2478-86

  12. CRYSTAL-AF: the more you look, the more you find 12.4% vs. 2.0% 30.0% vs. 3.0% Sanna et al. N Engl J Med 2014;370:2478-86

  13. EMBRACE: the more you look, the more you find Gladstone et al. N Engl J Med 2014;370:2467-77

  14. EMBRACE: the more you look, the more you find Gladstone et al. N Engl J Med 2014;370:2467-77

  15. EMBRACE: the more you look, the more you find Gladstone et al. N Engl J Med 2014;370:2467-77

  16. ESUS: Embolic Strokes of Undetermined Source Hart et al. Lancet Neurol 2014; 13: 429–38

  17. ESUS in the Athens Stroke Registry

  18. Ntaios et al. Stroke 2015; 46:176-81

  19. ESUS: patient characteristics Ntaios et al. Stroke 2015; 46:176-81

  20. ESUS: patient characteristics Ntaios et al. Stroke 2015; 46:176-81

  21. ESUS: patient characteristics Ntaios et al. Stroke 2015; 46:176-81

  22. ESUS: stroke severity Ntaios et al. Stroke 2015; 46:176-81

  23. ESUS & AF at follow-up: how much causality is there? • 81yrs • NIHSS:3 • Hypertensive, Non-smoker, non-diabetic • LDL: 104mg/dl • LA diameter: 42mm • mRS:0

  24. AF-related strokes are more severe Ntaios et al. Eur J Neurol. 2014; 21:1108-14

  25. ESUS & AF: how much of a causality? Ntaios et al, underreview

  26. ESUS: 5-yrs functional outcome Ntaios et al. Stroke 2015; 46:2087-93

  27. ESUS: 5-yrs stroke recurrence Ntaios et al. Stroke 2015; 46:2087-93

  28. So, how to treat my ESUS patient? Approach 1 Furie et al. Stroke 2011;42:227-76

  29. So, how to treat my ESUS patient? Approach 2

  30. So, how to treat my ESUS patient? Approach 3

  31. NAVIGATE- ESUS Rivaroxaban 15mg 1x1 R Aspirin 100mg 1x1

  32. RESPECT - ESUS Dabigatran 110/150 1x2 R Aspirin 100mg 1x1

  33. ATTICUS Apixaban R Aspirin 100mg 1x1

  34. Everybody gets happy! • Almost half stroke patients get an anticoagulant!

  35. Take-home messages • Cryptogenic  ESUS • ~10% of all stroke patients • ESUS needs a complete (?) diagnostic work-up • Covert AF is frequently detected in ESUS • Perhaps AF is over-estimated as a stroke cause • High recurrence rate • NOACs to replace antiplatelets?

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