From the Guidelines
Yes, a patent foramen ovale (PFO) can cause cryptogenic cerebral artery (CCA) stroke or transient ischemic attack (TIA). PFO is a small opening between the two upper chambers of the heart that normally closes shortly after birth but remains open in about 25% of adults. This opening can allow small blood clots to bypass the lungs' filtering system and travel directly to the brain, potentially causing a stroke or TIA. This mechanism is called paradoxical embolism. The risk is higher in people with larger PFOs, those with an associated atrial septal aneurysm, or those with conditions that increase clot formation.
Key Considerations
- Not all PFOs require treatment, but for patients who have had a stroke or TIA with no other identifiable cause, PFO closure with a device placed during a catheter procedure may be recommended to reduce the risk of recurrent events 1.
- Antiplatelet therapy (like aspirin or clopidogrel) or anticoagulation (like warfarin or direct oral anticoagulants) may also be prescribed depending on individual risk factors 1.
- The decision for PFO closure should be made after careful evaluation by both a cardiologist and neurologist.
Treatment Options
- For patients who are open to all options, PFO closure plus antiplatelet therapy is recommended rather than anticoagulant therapy 1.
- For patients in whom anticoagulation is contraindicated or declined, PFO closure plus antiplatelet therapy is recommended versus antiplatelet therapy alone 1.
- For patients in whom closure is contraindicated or declined, anticoagulant therapy is recommended rather than antiplatelet therapy 1.
From the Research
PFO and CCA or TIA
- PFO can be a cause of cryptogenic stroke or transient ischemic attack (TIA) 2, 3, 4, 5, 6
- Studies have shown that PFO closure can reduce the risk of recurrent stroke in selected patients with cryptogenic stroke or TIA 2, 3
- The benefit of PFO closure is particularly evident in patients with embolic appearing strokes, large right-to-left shunt, or an associated atrial septal aneurysm 3
- However, PFO closure is not without risks, and the annual risk of stroke from PFO is low relative to other stroke mechanisms 3
- The lifetime cumulative risk in young patients who have experienced a prior stroke may be substantial, in which case the absolute benefit of closure is likely impactful 3
Predictors of Recurrent Events
- Clinical predictors of recurrent ischemic stroke or TIA include diabetes, hypertension, and ischemic heart disease 4
- The detection of atrial fibrillation after study enrollment also independently predicted recurrent ischemic neurologic events 4
- Recurrent neurologic events were more frequent in subjects with a low RoPE (Risk of Paradoxical Embolism) score 4
- Pre-existing vascular risk factors, such as hypertension, and a hypercoagulable state were associated with recurrent ischemic stroke/TIA 6
PFO Closure and Recurrent Stroke/TIA
- Recurrent stroke/TIA after PFO closure can occur, with rates comparable to findings in previous trials 6
- New-onset atrial fibrillation was observed in some patients after PFO closure, but none of these patients subsequently developed an ischemic event 6
- Other adverse outcomes after PFO closure were uncommon 6