AUTHOR=Patel Kishan , Mikhael Elio , Liu Michael , Rangaraju Srikant , Ellis Deandra , Duncan Alexander , Belagaje Samir , Belair Trina , Henriquez Laura , Nahab Fadi 

TITLE=Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source Patients With Elevated Coagulation Markers or Severe Left Atrial Enlargement

JOURNAL=Frontiers in Neurology

VOLUME=Volume 12 - 2021

YEAR=2021

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2021.695378

DOI=10.3389/fneur.2021.695378

ISSN=1664-2295

ABSTRACT=Background
The objective of this study was to evaluate if anticoagulation therapy reduces recurrent stroke in embolic stroke of undetermined source (ESUS) patients with left atrial enlargement (LAE) or abnormal markers of coagulation and hemostatic activation (MOCHA) compared to antiplatelet therapy. 
Materials and Methods 
ESUS patients from January 1, 2017 to June 30, 2019 underwent outpatient cardiac monitoring and the MOCHA profile (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer). Anticoagulation was offered to patients with abnormal MOCHA (≥2 elevated markers) or left atrial volume index ≥40 ml/m2. Patients were evaluated for recurrent stroke or major hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy. 
Results 
Baseline characteristics in cohort 2 (n=196; mean age 63±16 years, 59% female, 49% non-white) were similar to cohort 1 (n=42) except that cohort 2 had less diabetes (43% vs 24%, p=0.01) and more tobacco use (26% vs 43%, p=0.04).  Overall, 45 (23%) patients in Cohort 2 initiated anticoagulation based on abnormal MOCHA or LAE. During mean follow up of 13 ± 10 months, Cohort 2 had significantly lower recurrent stroke rates than cohort 1 (14% vs. 3%, p=0.009) with no major hemorrhages. 
Conclusions 
Anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA or severe LAE may be associated with a reduced rate of recurrent stroke compared to antiplatelet therapy. A prospective, randomized study is warranted to validate these results.