From the Guidelines
Patients with a patent foramen ovale (PFO) and right-to-left shunt should generally be on aspirin therapy, typically at a dose of 81-325 mg daily, especially if they have experienced a cryptogenic stroke or transient ischemic attack (TIA). For patients with a PFO who have had a stroke or TIA, antiplatelet therapy with aspirin is considered first-line treatment if PFO closure is not performed, as supported by the 2018 Canadian Stroke Best Practice Recommendations 1.
Key Considerations
- The size of the PFO, degree of shunting, presence of an atrial septal aneurysm, and history of thromboembolism should be considered when making treatment decisions.
- PFO closure may be considered for very carefully-selected patients aged 60 years or younger with an unexplained embolic stroke event who are found to have a PFO and who do not require chronic anticoagulant therapy for another reason, as recommended by the 2018 Canadian Stroke Best Practice Recommendations 1.
- Antiplatelet therapy alone is recommended for secondary stroke prevention in patients with stroke or TIA who are aged >60 years, and those at any age whose PFO is most likely incidental rather than causal for the index stroke event.
Treatment Options
- Aspirin therapy is the preferred treatment for patients with PFO and right-to-left shunt who have experienced a cryptogenic stroke or TIA, as supported by the 2011 American Heart Association/American Stroke Association guidelines 2.
- Dual antiplatelet therapy (aspirin plus clopidogrel) or anticoagulation with warfarin or direct oral anticoagulants may be considered for higher-risk patients, as suggested by the 2013 American Heart Association scientific statement 3.
- PFO closure plus antiplatelet therapy is recommended for patients who are open to all options, as stated in the 2018 clinical practice guideline published in the BMJ 4.
Individualized Approach
- Treatment decisions should be individualized based on the patient's specific risk factors and medical history.
- Patient counseling and shared decision-making are important considerations, taking into account patient values and preferences, as emphasized in the 2018 Canadian Stroke Best Practice Recommendations 1.
From the Research
Patient Considerations for Aspirin Therapy
- Patients with a Patent Foramen Ovale (PFO) and right-to-left shunt may be considered for Aspirin (acetylsalicylic acid) therapy, as seen in studies 5, 6, 7.
- The use of Aspirin in these patients is often part of a broader anticoagulation regimen, aimed at preventing thromboembolic events 5, 6.
Efficacy and Safety of Aspirin Therapy
- Research suggests that Aspirin can be an effective and safe option for patients with PFO and right-to-left shunt, with a low incidence of major bleeding complications 6, 7.
- Studies have shown that Aspirin can help prevent device thrombosis and thrombotic complications after interatrial shunt device-based closure 6.
- However, the optimal duration of Aspirin therapy is not well established, with some studies suggesting a 6-month regimen 6 and others recommending lifelong treatment in certain cases 7.
Comparison with Other Therapies
- The efficacy of Aspirin therapy compared to other anticoagulation regimens, such as oral anticoagulation, is not well established 7.
- Some studies suggest that device closure of PFO, in combination with Aspirin therapy, may be more effective in preventing stroke recurrence than medical therapy alone 8.
- However, the decision to use Aspirin therapy should be made on a case-by-case basis, taking into account individual patient characteristics and risk factors 9, 8.
Clinical Guidelines and Recommendations
- Clinical guidelines recommend the use of Aspirin in patients with cryptogenic stroke and PFO, particularly in those with moderate or extensive right-to-left shunt 7.
- The American Heart Association and other organizations have published guidelines on the management of PFO and cryptogenic stroke, which include recommendations for Aspirin therapy 7, 8.