Management of Stroke Patients With a PFO

Jan 05, 2021
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Authors:
Dia AR, Cifu AS, Shah AP.
Citation:
Management of Patients With a Patent Foramen Ovale With History of Stroke or TIA. JAMA 2021;325:81-82.
Summary By:
Mollie McDermott, MD, MS

Quick Takes

  • PFOs are highly prevalent anatomic variants associated with ischemic stroke via paradoxical embolism.
  • Closure of PFO after ischemic stroke is beneficial in cases where the PFO was highly likely to have caused the stroke.
  • The best antithrombotic regimen (antiplatelet vs. anticoagulation) for stroke patients with PFO who do not undergo closure is not clear at this time.

Study Questions:

What is the role of patent foramen ovale (PFO) closure in secondary stroke prevention?

Methods:

This is a clinical guideline synopsis created by a group of content experts after review of the eight core PFO closure studies.

Results:

All patients for whom PFO closure is being considered should have an electrocardiogram to evaluate for atrial fibrillation. Patients >50 years of age with risk factors for atrial fibrillation (hypertension, obesity, obstructive sleep apnea, etc.) should have at least 28 days of cardiac event monitoring to evaluate for atrial fibrillation. In all patients, alternative (non-PFO) causes of ischemic stroke in addition to atrial fibrillation should be excluded; these include extracranial or intracranial vessel stenosis and small vessel ischemic disease.

Conclusions:

This guideline synopsis provides a moderate recommendation for PFO closure in patients younger than 60 years who do not have another identifiable cause of stroke after a comprehensive workup. Patients who do not undergo PFO closure and have no other clear stroke etiology should be started on an antithrombotic, though at this time it is unclear whether an antiplatelet or anticoagulation is preferred.

Perspective:

PFOs are common, occurring in up to 25% of the general population. When a PFO is felt to be very likely responsible for a patient’s stroke, PFO closure provides a moderate benefit for patients under the age of 60 years. Shared decision making is key because of the overall low risk of disabling stroke regardless of closure status, and because it is difficult to determine with certainty whether a patient’s PFO caused his or her stroke. Extrapolating from the NAVIGATE ESUS and RE-SPECT ESUS trial results, it seems most prudent at this time to recommend antiplatelet therapy rather than anticoagulation for stroke patients with PFO who opt not to receive closure.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Hypertension, Sleep Apnea

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Ischemia, Constriction, Pathologic, Electrocardiography, Fibrinolytic Agents, Foramen Ovale, Patent, Heart Defects, Congenital, Hypertension, Ischemic Attack, Transient, Obesity, Platelet Aggregation Inhibitors, Risk Factors, Secondary Prevention, Sleep Apnea, Obstructive, Stroke, Vascular Diseases


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