Abstract 4371442: Aspirin Shows Comparable Efficacy to Other Antithrombotic Strategies in Preventing Recurrent Stroke in Patients with Aortic Arch Atheroma: A Systematic Review

Introduction: Atherosclerotic plaques ≥4 mm in the aortic arch are strongly associated with recurrent stroke, particularly in cases of undetermined etiology. Guidelines such as the 2021 Stroke Guideline highlight the lack of conclusive evidence regarding the optimal antithrombotic strategy in this patient population. Objective: To compare the efficacy of antithrombotic therapies in preventing recurrent stroke in patients with stroke or transient ischemic attack (TIA) and aortic arch atheroma ≥4 mm. Methods: A systematic review was conducted using PubMed/MEDLINE, EMBASE, and Scopus databases through April 2025. Randomized clinical trials and observational studies comparing aspirin, dual antiplatelet therapy (DAPT), rivaroxaban, warfarin, or ticagrelor in patients with stroke/TIA and evidence of aortic arch plaques were included. It was hypothesized that alternative therapies would offer superior protection against recurrent stroke. Results: Four studies (three randomized trials and one observational study) totaling 4,399 patients were included. Most patients had ischemic stroke or TIA, hypertension, dyslipidemia, diabetes mellitus, and were smokers. No statistically significant superiority was observed for alternatives over aspirin: warfarin (RR 1.07; 95% CI: 0.72–1.58; p=0.75), ticagrelor (RR 0.90; 95% CI: 0.68–1.18; p=0.43), rivaroxaban (RR 1.19; 95% CI: 0.89–1.61; p=0.24), and warfarin versus antiplatelets (RR 1.03; 95% CI: 0.72–1.48; p=0.87). Conclusion: The analyzed therapies did not demonstrate clinical superiority over aspirin in preventing recurrent ischemic stroke in patients with aortic arch atheroma. Aspirin monotherapy remains the most consistent approach; however, further studies are needed to inform clinical decisions in this subgroup. Artificial intelligence tools were used under human supervision to assist in adapting the abstract to the American Heart Association submission format.