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Canadian Journal of Cardiology

EMBOLIC STROKE OF UNDETERMINED SOURCE: CURRENT PERSPECTIVES ON DIAGNOSIS, INVESTIGATIONS AND MANAGEMENT

Published:October 19, 2022DOI:https://doi.org/10.1016/j.cjca.2022.10.017

      Abstract

      In 2014, Hart et al. introduced the concept of “Embolic Stroke of Undetermined Source” (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, two large clinical trials have demonstrated that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform post-stroke workup, and secondary prevention strategies. Here, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing and anticipated clinical trials that will guide earlier and later secondary prevention strategies and post-stroke cardiac investigations.
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