What is the initial management approach for patients with a patent foramen ovale (PFO)?

From the Guidelines

The initial management approach for patients with a patent foramen ovale (PFO) should prioritize antiplatelet therapy, with PFO closure considered for carefully selected patients under 60 years with cryptogenic stroke and high-risk PFO features. For asymptomatic patients with incidentally discovered PFOs, observation without specific treatment is typically recommended as these defects carry minimal risk [ 1 ]. For patients who have experienced a cryptogenic stroke with a PFO, antiplatelet therapy with aspirin (81-325 mg daily) is often the first-line treatment [ 1 ]. In cases of recurrent stroke despite antiplatelet therapy, or in patients with high-risk PFO features (large shunt, atrial septal aneurysm), anticoagulation with warfarin or direct oral anticoagulants may be considered [ 1 ]. Some key points to consider in the management of PFO include:

• PFO closure via percutaneous device placement is reserved for patients under 60 years with cryptogenic stroke and high-risk PFO features who have failed medical therapy [ 1 ].
• Lifestyle modifications including smoking cessation and maintaining healthy blood pressure are also important components of management.
• Patient counseling and shared decision-making, taking into account patient values and preferences, are important considerations [ 1 ].
• The benefits and risks of PFO closure, including the risk of procedural complications such as atrial fibrillation, should be carefully weighed [ 1 ]. Recent studies, including the CLOSE trial [ 1 ] and the REDUCE trial [ 1 ], have demonstrated the effectiveness of PFO closure in preventing recurrent stroke in carefully selected patients. However, the decision to proceed with PFO closure should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history [ 1 ].

From the Research

Initial Management Approach for Patients with Patent Foramen Ovale (PFO)

The initial management approach for patients with a patent foramen ovale (PFO) depends on various factors, including the presence of cryptogenic stroke, atrial septal aneurysm, or large interatrial shunt.

• The optimal antithrombotic strategy is still unclear, but studies suggest that anticoagulation may not convey a net benefit in prevention of recurrent stroke compared to antiplatelet treatment 2.
• PFO closure plus antiplatelet therapy may result in a substantial reduction in ischemic stroke recurrence compared to antiplatelet therapy alone, especially in patients with high-risk features such as atrial septal aneurysm or large interatrial shunt 3, 4, 5.
• Anticoagulation may reduce the risk of ischemic stroke recurrence, but it also increases the risk of major bleeding 3, 5.
• The choice of management strategy should be individualized based on patient characteristics, risk factors, and the presence of contraindications to certain treatments.

Comparison of Management Strategies

• PFO closure vs. antiplatelet therapy: PFO closure may be associated with a lower risk of recurrent stroke, but it also increases the risk of procedural complications and atrial fibrillation 4, 5.
• PFO closure vs. anticoagulation: PFO closure may be associated with a lower risk of major bleeding, but the difference in stroke recurrence is uncertain 3, 5.
• Anticoagulation vs. antiplatelet therapy: Anticoagulation may reduce the risk of ischemic stroke recurrence, but it also increases the risk of major bleeding 2, 3, 5.

Patient Selection and Risk Stratification

• The RoPE score may help in selecting patients who would benefit from anticoagulation 2.
• Patients with high-risk features such as atrial septal aneurysm or large interatrial shunt may benefit from PFO closure or anticoagulation 3, 4, 5.
• Further studies are needed to delineate the risk/benefit profile of different management strategies and to develop personalized treatment approaches for patients with PFO.