Комбинированная антиагрегантная терапия и антикоагулянты не снижают риск повторного инсульта у пациентов с эмболическим инсультом неясного генеза

Anticoagulation and combination antiplatelet therapy do not reduce the risk for recurrent stroke or other major adverse outcomes compared with single antiplatelet therapy among patients with embolic stroke of undetermined source, according to study findings published in Neurology: Clinical Practice. Researchers analyzed data from the multicenter Cardiac Abnormalities in Stroke Prevention and Risk of Recurrence (CASPR) registry (ClinicalTrials.gov identifier: NCT06398366) to characterize contemporary antithrombotic prescribing patterns and evaluate clinical outcomes following embolic stroke of undetermined source. This retrospective observational cohort study included consecutive adults with embolic stroke of undetermined source admitted to 27 comprehensive stroke centers in the US between 2015 and 2023. Patients were grouped according to the antithrombotic regimen initiated within 7 days after stroke or before hospital discharge, whichever occurred first. Treatment groups included single antiplatelet therapy (SAPT), combination antiplatelet therapy (CAPT), and anticoagulation with or without antiplatelet therapy (AC±AP). The primary composite outcome comprised recurrent ischemic stroke, major bleeding, intracerebral hemorrhage, or death. A more detailed phenotypic analysis of [embolic stroke of undetermined source] patients in the CASPR study is under way and may provide insights into distinct patient profiles which may benefit from one antithrombotic strategy over another. The analysis included 2328 patients, 66.0% of whom received SAPT, 24.1% CAPT, and 9.9% AC±AP. The median patient age was 65 years, 49.7% were women, and hypertension (69.6%), dyslipidemia (46.9%), diabetes (27.0%), and atherosclerotic vascular disease (32.4%) were common baseline characteristics. The median follow-up duration was 593 days. Baseline clinical characteristics differed across treatment groups. Compared with patients receiving SAPT, those treated with CAPT were more likely to have hypertension, diabetes, dyslipidemia, coronary artery disease, and other atherosclerotic vascular disease and were more likely to present with milder neurologic deficits. Patients receiving AC±AP were generally younger but more often had a history of prior stroke, higher National Institutes of Health Stroke Scale scores, large vessel occlusion, and left ventricular injury. Prescribing practices also shifted over the study period. Compared with patients treated between 2015 and 2018, those treated between 2019 and 2023 were more likely to receive CAPT (26.7% vs 16.8%) or AC±AP (11.6% vs 5.8%) and less likely to receive SAPT (61.7% vs 77.5%; P <.01), despite randomized trials showing no superiority of anticoagulation over antiplatelet therapy in patients with embolic stroke of undetermined source. More intensive antithrombotic strategies did not translate into better clinical outcomes. After multivariable adjustment, neither CAPT nor AC±AP reduced the risk for the primary composite outcome compared with SAPT. The researchers also observed no significant differences between treatment groups in recurrent ischemic stroke or intracerebral hemorrhage. Anticoagulation was associated with a higher unadjusted risk for major bleeding than SAPT (hazard ratio [HR], 2.04; 95% CI, 1.04-3.98), although this association was no longer statistically significant after multivariable adjustment. One significant finding emerged among the secondary outcomes: patients treated with CAPT had a lower adjusted risk for death than those receiving SAPT (adjusted HR, 0.69; 95% CI, 0.48-0.98). No mortality benefit was observed with anticoagulation. The researchers also identified older age, greater stroke severity, prestroke disability, and underlying atherosclerotic vascular disease as independent predictors of the primary composite outcome, whereas the presence of a patent foramen ovale was associated with a lower risk. Subgroup analyses largely demonstrated consistent findings across patient populations. The only subgroup in which anticoagulation was associated with a lower risk for recurrent ischemic stroke was among patients without a prior history of stroke. Study limitations include the retrospective design, potential selection bias, variation in treatment practices across participating centers, lack of information regarding the rationale for antithrombotic selection, and the absence of data on treatment duration, adherence, and crossover between therapies. “A more detailed phenotypic analysis of [embolic stroke of undetermined source] patients in the CASPR study is under way and may provide insights into distinct patient profiles which may benefit from one antithrombotic strategy over another,” the study authors concluded. Disclosures: This research was supported by Medtronic and Philips. Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures. References: Aboul-Nour H, Siegler JE, Thompson SL, et al. Real-world practice in secondary stroke prevention following embolic stroke of undetermined source: secondary analysis of the CASPR registry. Neurol Clin Pract. 2026;16:e200631. doi:10.1212/CPJ.0000000000200631