From the Guidelines
A person with a PFO typically requires DAPT for 1-6 months after PFO closure, followed by single antiplatelet therapy (SAPT) for up to 5 years. The management of a patent foramen ovale (PFO) depends on various factors, including the defect type, procedure type, and patient characteristics, such as bleeding and thrombotic risk, and the presence of comorbidities 1. According to recent guidelines, after PFO closure, 1–6 months of DAPT is recommended, followed by SAPT for up to 5 years, with prolongation beyond 5 years determined by the stroke and bleeding risks of the patient 1.
The choice of antiplatelet drug type is empirical, and data suggest that all patients with a history of ischemic stroke might be candidates for lifelong antithrombotic treatment, regardless of PFO closure 1. Key considerations in the decision for treatment include:
- The patient's risk factors for stroke
- The size of the PFO
- Presence of an atrial septal aneurysm
- Other cardiovascular conditions In an observational study of 660 patients undergoing PFO closure after embolic stroke of undetermined source, thromboembolic events occurred in 25 patients (3.8%) within 5 years of follow-up, highlighting the importance of careful management and follow-up 1.
From the Research
Antithrombotic Therapy for Patients with Patent Foramen Ovale (PFO)
- The optimal antithrombotic strategy for patients with cryptogenic stroke and PFO is still debated 2, 3, 4, 5.
- Studies have compared the efficacy and safety of anticoagulation versus antiplatelet therapy in patients with PFO-related stroke 2, 3, 4, 5.
- A meta-analysis of randomized controlled trials found that anticoagulation conveyed no net benefit in prevention of recurrent stroke compared with antiplatelet treatment, but may be beneficial in patients with high RoPE score 2.
- Another study found that dabigatran was superior to aspirin for stroke prevention in patients with cryptogenic stroke and PFO, with no increased risk of bleeding complications 3.
Dual Antiplatelet Therapy (DAPT)
- DAPT with clopidogrel and aspirin may provide greater protection against subsequent stroke than monotherapy in patients with ischemic stroke or transient ischemic attack (TIA) 6.
- Short-duration DAPT (≤ 1 month) started during the early acute ischemic phase was associated with less bleeding and greater reduction of recurrent strokes compared with monotherapy 6.
- However, the use of DAPT in patients with PFO is not well established, and further studies are needed to determine its efficacy and safety in this population.
Comparison of Antithrombotic Strategies
- A meta-analysis of 16 studies found that oral anticoagulation (OAC) was associated with a significant reduction in the risk of stroke compared with antiplatelet therapy (APT) in patients with PFO and cryptogenic stroke 4.
- Another study found that OAC was more effective than APT in reducing the risk of stroke recurrence in patients with PFO and CS, without a significant increase in the risk of major bleedings 4.
- However, individual participant data meta-analysis found that the difference between OAC and APT was not statistically significant for the primary composite outcome or for the secondary outcome of stroke alone 5.