What is the best anticoagulant for the treatment of Patent Foramen Ovale (PFO)?

From the Guidelines

For patients with a patent foramen ovale (PFO) requiring anticoagulation, aspirin (81-325 mg daily) is generally the first-line recommendation for most patients with cryptogenic stroke attributed to PFO, particularly those who have undergone PFO closure or have lower risk profiles. For higher-risk patients or those with recurrent events despite aspirin therapy, oral anticoagulation with direct oral anticoagulants (DOACs) like apixaban (5 mg twice daily), rivaroxaban (20 mg daily), or dabigatran (150 mg twice daily) is preferred over warfarin due to their favorable safety profile and ease of use 1. The duration of therapy is typically lifelong for patients who do not undergo PFO closure, while those who have closure may receive antiplatelet therapy for 3-6 months post-procedure followed by reassessment. The choice between antiplatelet therapy and anticoagulation should be individualized based on the patient's risk factors, including the presence of atrial septal aneurysm, large shunt size, history of recurrent strokes, and hypercoagulable states. Some key points to consider in the decision-making process include:

• The results of the CLOSE trial, which demonstrated that PFO closure was superior to medical therapy for prevention of stroke recurrence in carefully-selected patients 1
• The findings of the REDUCE trial, which showed that PFO closure reduced the rate of ischemic stroke compared to antiplatelet-only therapy 1
• The recommendations of the clinical practice guideline, which suggest PFO closure plus antiplatelet therapy as a weak recommendation for patients who are open to all options 1 Anticoagulation provides more potent protection against thrombus formation but carries a higher bleeding risk compared to antiplatelet therapy, making the risk-benefit assessment crucial in treatment selection. Ultimately, the decision should be based on individual patient characteristics and risk versus benefit profile, taking into account the patient's values and preferences.

From the Research

Anticoagulant Treatment for PFO

The optimal antithrombotic strategy for patients with patent foramen ovale (PFO) and cryptogenic stroke is still unclear.

• A systematic review and meta-analysis of randomized controlled trials found that anticoagulation conveyed no net benefit in prevention of recurrent stroke compared with antiplatelet treatment, and associated with a non-significant higher risk of major bleeding 2.
• Another study found that in patients with a higher risk alternative mechanism of stroke identified, clinicians should not routinely recommend PFO closure, and that anticoagulation may be recommended for patients who opt to receive medical therapy alone without PFO closure 3.

Comparison of Anticoagulation and Antiplatelet Therapy

• A network meta-analysis found that anticoagulation, compared with antiplatelet therapy, may reduce the risk of ischemic stroke recurrence, but probably increases the risk of major bleeding 4.
• A systematic review and meta-analysis found that anticoagulant-assigned patients had a lower rate of stroke recurrence compared with antiplatelet-assigned patients, but with no significant differences in major bleeding 5.

Device Closure and Antithrombotic Treatment

• A study found that percutaneous PFO closure is an intervention aimed to prevent cardioembolic stroke, and that various types of devices with different characteristics are currently available for the use of the interventionists 6.
• The choice of device for PFO closure should be based on the patient's clinical features and the various PFO anatomies, and a road-map of choice among the various prostheses is provided 6.

Key Findings

• Anticoagulation may not be superior to antiplatelet therapy in preventing recurrent strokes in patients with PFO and cryptogenic stroke 2, 5.
• PFO closure may be recommended for patients with a high risk of recurrent stroke and no other mechanism of stroke identified 3, 4.
• The choice of antithrombotic treatment and device for PFO closure should be individualized based on the patient's clinical features and the various PFO anatomies 3, 4, 6.