Do you recommend closing a patent foramen ovale (PFO) in a 64-year-old patient?

PFO Closure in a 64-Year-Old Patient

PFO closure is not recommended for a 64-year-old patient with PFO unless they have had a cryptogenic stroke, as the benefits of closure are less certain and the risks potentially greater in patients over 60 years of age. 1

Age-Related Considerations for PFO Management

• The 2018 BMJ clinical practice guideline specifically notes that PFO closure recommendations apply primarily to patients under 60 years old 1
• In older patients (>60 years), fewer cryptogenic strokes are caused by paradoxical emboli, making the benefits of PFO closure smaller while the risks may be greater 1
• Age is a significant determinant of stroke recurrence risk in patients with PFO, with different risk-benefit profiles in older populations 2

Decision Algorithm for PFO Closure in Older Adults

1. History of Cryptogenic Stroke

   • If NO prior stroke: PFO closure is not indicated
   • If YES (cryptogenic stroke): Proceed to next step

2. PFO Characteristics Assessment

   • High-risk features that might warrant consideration despite age:
     • Large right-to-left shunt
     • Associated atrial septal aneurysm
     • Multiple previous neurological events 3

3. Risk Stratification Tools

   • Apply RoPE Score (Risk of Paradoxical Embolism) 4
   • Use PASCAL Classification (PFO-Associated Stroke Causal Likelihood) 4
   • Lower scores in these systems reduce likelihood of benefit from closure

4. Alternative Stroke Etiologies

   • Must exclude other causes of stroke before attributing to PFO
   • PFO is present in approximately 25% of the general population and often incidental 5

Evidence on PFO Closure in Older Adults

• Real-world data shows higher recurrent stroke rates (7%) after PFO closure in patients >60 years compared to younger patients (2.9%) 6
• For patients ≥60 years, the pooled ischemic stroke risk is 3.27 per 100 patient-years even with medical therapy 2
• The 2018 BMJ guideline explicitly states that applicability of PFO closure findings to patients over 60 is "more uncertain" 1

Management Options If PFO Closure Is Not Performed

1. Antiplatelet Therapy

   • First-line treatment for patients with PFO without other indications for anticoagulation 4
   • Typically aspirin 81-325mg daily

2. Anticoagulation Therapy

   • Consider if there are other indications (hypercoagulable states, venous thrombosis)
   • May be superior to antiplatelet therapy in preventing recurrent events 1

3. Risk Factor Modification

   • Control of blood pressure
   • Smoking cessation
   • Appropriate physical activity
   • Maintenance of hydration 4

Pitfalls to Avoid

• Recommending PFO closure in patients >60 years without strong evidence of benefit is considered overtreatment 4
• Assuming PFO causality in older patients when the PFO is more likely incidental 4
• Neglecting to perform comprehensive evaluation for other stroke etiologies 4
• Routine surveillance imaging for incidental PFO is not recommended 4

In conclusion, for a 64-year-old patient with PFO but no history of cryptogenic stroke, PFO closure is not recommended. If the patient has had a cryptogenic stroke, medical therapy with antiplatelet or anticoagulant medications is generally preferred over PFO closure due to the less favorable risk-benefit profile in this age group.