Ashkan Shoamanesh, MD, McMaster University, Hamilton, Canada, discusses hot topics in stroke prevention and anticoagulation. Firstly, the ELAN trial (NCT03148457) shed light on major uncertainties surrounding the initation/resumption of anticoagulation in patients with ischemic stroke due to atrial fibrillation (AF), demonstrating a reduced risk of a recurrent events with early anticoagulation compared to a later start (not statistically significant), without an increase in risk of major bleeding complications. Since the data suggests early initiation is probably better and unlikely to cause harm, Dr Shaomanesh believes it is likely anticoagulation will now be initiated earlier due to these results. Another important trial is the ARCADIA trial (NCT03192215), comparing the use of apixaban to aspirin for the prevention of recurrent stroke in patients with cryptogenic ischemic stroke and atrial cardiopathy. The trial was stopped at interim analysis due to futility, where no of benefit for recurrent stroke prevention was seen with apixaban use. This research also raises questions about the management of brief duration atrial fibrillation (AF), as it can be assumed that many of these patients would show some level of AF on long term cardiac monitoring. The results highlight that the benefit of anticoagulation for patients with brief AF on long-term cardiac monitoring cannot be assumed, aligning with prior findings from the ATTICUS trial (NCT02427126). Dr Shaomanesh also outlines the implications of these findings for future investigations in embolic strokes of undetermined source (ESUS) populations, particularly the promise of dual-pathway inhibition. This interview took place during the European Stroke Organisation Conference (ESOC) in Munich, Germany.

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