From the Guidelines
An incidental patent foramen ovale (PFO) without associated symptoms or complications generally requires no specific treatment or intervention. For most individuals with an incidentally discovered PFO, clinical observation is the recommended approach, as the majority of these defects pose minimal risk and do not cause symptoms. No antiplatelet therapy or anticoagulation is routinely recommended for asymptomatic PFOs. However, patients should be educated about their condition and advised to seek medical attention if they develop symptoms such as transient neurological deficits, shortness of breath, or palpitations.
In certain specific scenarios, such as when a PFO is discovered after a cryptogenic stroke or transient ischemic attack, management may include antiplatelet therapy (typically aspirin 81-325 mg daily), consideration of anticoagulation (such as warfarin with INR 2-3 or direct oral anticoagulants), or possible PFO closure, as suggested by studies such as 1. The decision to pursue more aggressive management depends on individual risk factors, including the size of the PFO, presence of an atrial septal aneurysm, history of deep vein thrombosis, hypercoagulable states, and recurrent events despite medical therapy.
Some key points to consider in the management of PFO include:
- The high prevalence of PFO in the general population (approximately 25%) and the low absolute risk of adverse events in asymptomatic individuals, as noted in 1 and 1.
- The importance of individualized decision-making, taking into account patient values and preferences, as emphasized in 1.
- The need for further research to establish the optimal management strategy for patients with cryptogenic stroke and PFO, as highlighted in 1, 1, 1, 1, and 1.
Overall, the management of incidental PFO should prioritize a conservative approach, reserving more aggressive interventions for patients with specific risk factors or symptoms.
From the Research
Management Approach for Incidental Patent Foramen Ovale (PFO)
The management of an incidental patent foramen ovale (PFO) depends on various factors, including the patient's medical history and the presence of any symptoms.
- Current guidelines recommend closing a PFO in patients who have experienced a cryptogenic or cardioembolic stroke, have a high-risk PFO, and are aged between 16 and 60 years [ 2 ].
- The decision to close a PFO should be made on a case-by-case basis, considering the individual patient's risk factors and medical history [ 2 ].
PFO Closure vs. Medical Therapy
Several studies have compared the efficacy of PFO closure versus medical therapy in preventing stroke recurrence.
- A systematic review and meta-analysis found that PFO closure plus medical therapy was more effective in preventing stroke recurrence than medical therapy alone in selected adult patients with PFO and a history of cryptogenic stroke [ 3 ].
- Another study found that anticoagulation conveyed no net benefit in preventing recurrent stroke compared to antiplatelet treatment, but may be beneficial in patients with a high RoPE score [ 4 ].
- A meta-analysis of randomized controlled trials found that anticoagulant treatment did not significantly reduce the risk of recurrent stroke compared to antiplatelet treatment, but may be associated with a higher risk of major bleeding [ 5 ].
Patient Selection for PFO Closure
Patient selection is crucial in determining the benefits and risks of PFO closure.
- Patients with a large right-to-left shunt, an atrial septal aneurysm, and no evidence of atrial fibrillation may benefit from PFO closure [ 6 ].
- The RoPE score may be useful in selecting patients who are likely to benefit from anticoagulation [ 4 ].
Treatment of Migraine with PFO
There is currently no evidence to support PFO closure as a treatment for migraine [ 2 , 6 ].