Comprehensive Diagnostic Evaluation and Risk of Recurrent Stroke After Embolic Stroke of Undetermined Source: Introducing the Concept of ESUS 2.0.
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Khan Farhan, Stretz Christoph, Lewis Skylar, Chahien Dalia, Goldstein Eric, Siegler James E, Lineback Christina M, Eklund Kelsey, Khasiyev Farid, Al Kasab Sami, Culbertson Collin J, D'Souza Marissa, Stamm Brian, Ro Jennifer, Kerrigan Deborah, Sharma Richa, Aboul-Nour Hassan, Nahab Fadi, Omran Setareh Salehi, Linares Guillermo, Sehgal Siddharth, Melkumova Emiliya, Singh Eesha, Zha Alicia M, Thottempudi Neeharika, Mannion Shani, Van Coevering Russel, Chen Lucia, Thompson Sean L, Thon Jesse M, Penckofer Mary, Yu Wenzheng, Qdais Ahmad Abu, Jillella Dinesh, Sloane Kelly L, Dumitrascu Oana M, Conyers Frank G, Talat Fawad, Glover Patrick A, Kang Jieun, Patel Vivek, Aziz Yasmin, Zubair Adeel, de Havenon Adam, Porto Camelia Valhuerdi, Bowman Anna, Shahrivari Mahan, Brorson James R, Liebeskind David S, Nedelcu Simona, Ali Hamid, Abdalwahab Ahmed, Kam Wayneho, Nguyen Thanh N, Herpich Franziska, Farroqui Mudassir, Rojas-Soto Diana, Yaghi Shadi
Аннотация
METHODS: This was a retrospective analysis of a multicenter observational cohort study (n=27 sites). ESUS was categorized into 3 groups: (1) established mechanism after further workup (ESUS-E), (2) comprehensive diagnostic workup without an identified cause (ESUS 2.0), and (3) no advanced workup. The primary outcome of recurrent ischemic stroke was compared between ESUS with established mechanism and ESUS 2.0 versus ESUS with no advanced workup and was assessed using adjusted Cox proportional hazards models.
RESULTS: Among 2281 patients, the mean age was 65 years, and 50.1% were men. 694 (30.4%) classified as ESUS-E, 1,243 (54.5%) classified as ESUS-NAW, and 344 (15.1%) as ESUS 2.0. The ESUS 2.0 group had a significantly lower risk of recurrent stroke than both the group with ESUS with no advanced workup (adjusted hazard ratio [aHR], 0.31 [95% CI, 0.13-0.76]) and the group with ESUS with established mechanism (aHR, 0.35 [95% CI, 0.15-0.85]). Within the group with ESUS with established mechanism, cancer (aHR, 5.33 [95% CI, 2.09-13.63]) and nonstenosing atherosclerotic disease or arch atheroma (aHR, 3.40 [95% CI, 1.18-9.83]) were associated with significantly increased risk of recurrence when compared with the group with ESUS 2.0.
CONCLUSIONS: These findings demonstrate a lower risk of recurrent stroke in patients classified as ESUS 2.0 than reported in prior ESUS trials and highlight the importance of age-appropriate advanced diagnostic evaluation.
REGISTRATION: URL: https://www.clinicaltrials.gov. Identifier: NCT06398366.