Post-CVA Management for Patients with Patent Foramen Ovale (PFO)
After experiencing a small CVA (stroke) from a Patent Foramen Ovale (PFO), you should avoid activities that increase right-to-left shunting and pursue PFO closure with subsequent antiplatelet therapy as the optimal management strategy to prevent recurrent stroke.
Key Activities and Factors to Avoid
Immediate Post-Stroke Period
- Avoid Valsalva maneuvers that increase right-to-left shunting through the PFO
- Avoid strenuous activities during initial recovery period (typically first few weeks)
- Avoid activities with high injury risk that could lead to bleeding complications while on antithrombotic therapy
Long-Term Considerations
- Avoid smoking as it increases stroke risk
- Avoid uncontrolled hypertension through proper medication adherence
- Avoid excessive alcohol consumption
- Avoid dehydration which can increase blood viscosity
Optimal Management Strategy
PFO Closure Recommendation
PFO closure followed by antiplatelet therapy is strongly recommended over antiplatelet therapy alone for patients who have experienced a cryptogenic stroke attributed to PFO 1. This approach:
- Reduces absolute stroke risk by 8.7% over 5 years compared to antiplatelet therapy alone 1, 2
- Provides substantial long-term protection against recurrent stroke 3
If PFO Closure Is Pursued
- Timing: Typically performed 2-4 weeks after the acute stroke when risk of hemorrhagic transformation is low 2
- Procedure details:
- Takes under 2 hours
- Usually requires only one day of hospitalization
- Most activities can be resumed within a few days
- Full recovery typically occurs within a few weeks 1
- Post-closure medication:
- Antiplatelet therapy (typically aspirin) is continued for at least 1-6 months, often up to 5 years 1
If PFO Closure Is Not an Option
If PFO closure is contraindicated or declined, anticoagulation therapy is preferred over antiplatelet therapy alone 1:
- Anticoagulation may decrease ischemic stroke by 7.1% (absolute risk reduction over 5 years)
- However, it increases major bleeding risk by 1.2% (absolute risk increase over 5 years) 1
Potential Complications to Be Aware Of
PFO Closure Complications
- Device-related adverse events (3.6% absolute risk) 1, 2
- Increased risk of atrial fibrillation (1.8% absolute risk increase) 1
- Most procedure-related complications do not result in long-term disability 1
Anticoagulation Complications
- Increased risk of major bleeding compared to antiplatelet therapy 1
- Requires regular monitoring if using warfarin
- Potential food and drug interactions
Patient Selection Considerations
The benefit of PFO closure is particularly evident in:
- Younger patients (typically under 60 years) 4
- Patients with embolic-appearing strokes 5
- Those with large right-to-left shunt or associated atrial septal aneurysm 6
- Patients with high RoPE scores (Risk of Paradoxical Embolism) 4
There may be little or no benefit in patients with:
- Small deep infarcts
- A small PFO
- An indication for long-term anticoagulation for other reasons 5
Follow-up Recommendations
- Clinical follow-up at 1 month, 6 months, and annually thereafter
- Echocardiography at 3-6 months post-closure to confirm device position and absence of residual shunt 2
- Continued risk factor modification, including blood pressure control and lipid management
By following these recommendations and avoiding activities that increase right-to-left shunting, you can significantly reduce your risk of experiencing another stroke related to your PFO.