This meta-analysis compared the efficacy and safety of anticoagulation (AC) and antiplatelet therapies in preventing recurrent stroke after ESUS.

A systematic search of electronic databases and conference proceedings identified randomized controlled trials comparing anticoagulation and antiplatelet therapies in adult ESUS patients. The primary outcome was the composite of ischemic stroke and major bleeding. Secondary outcomes included recurrent stroke, mortality, and bleeding complications.

Four trials with a total of 13,970 patients (6,989 AC, 6,981 antiplatelet), were included. The primary outcome occurred in 7.22% of antiplatelet patients and 1.59% of anticoagulation patients (RR 1.04, 95% CI: 0.88-1.24, p=0.63). Recurrent stroke or ischemic embolism rates were 6.04% (antiplatelet) and 5.65% (anticoagulation) (RR 0.94, 95% CI 0.77-1.13, p=0.49). Mortality rates were 1.75% (antiplatelet) and 1.95% (anticoagulation) (RR 1.11, 95% CI: 0.87-1.42, p=0.63). Major bleeding occurred in 1.43% (antiplatelet) and 2.13% (anticoagulation) (RR 1.24, 95% CI 0.59-2.59, p=0.58). Clinically relevant non-major bleeding was significantly higher with antiplatelet therapy (RR 1.52, 95% CI 1.20-1.50, p=0.0006).