| New Recommendation | Aspirin is recommended as secondary prevention for patients with ESUS, and NOACs are not recommended. | III | B |
| The NAVIGATE-ESUS trial randomly assigned 7213 patients to receive either 15 mg/day of rivaroxaban or 100 mg/day of aspirin. The results showed that there were 172 cases (4.8%) of stroke or systemic embolism in the rivaroxaban group compared with 160 cases (4.4%) in the aspirin group (5.1% vs 4.8%, p=0.52). However, rivaroxaban had a higher rate of major bleeding than aspirin (1.8% vs 0.7%, p<0.001).236 The RESPECT-ESUS trial randomised 5390 patients into two groups: the dabigatran group and the aspirin group. During a median follow-up of 19 months, there were 117 cases (6.6%) of recurrent stroke in the dabigatran group and 207 cases (7.7%) in the aspirin group (annualised rates of 4.1% vs 4.8%, p=0.10). The incidence of major bleeding was similar between the two groups (annualised rates of 1.7% vs 1.4%, p=0.30).237
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