How should a patient with a large patent foramen ovale (PFO) and sinus tachycardia be managed?

Management of a Patient with Large PFO and Sinus Tachycardia

Patients with a large patent foramen ovale (PFO) and sinus tachycardia should be managed with PFO closure plus antiplatelet therapy if they have had a cryptogenic stroke or TIA, are between 18-60 years old, and the PFO is determined to be the most likely cause of the event after thorough evaluation.

Initial Assessment of PFO and Sinus Tachycardia

Diagnostic Workup

• Transesophageal echocardiography (TEE) with saline contrast injection is the diagnostic technique of choice for confirming PFO and assessing its characteristics 1
• Evaluate for high-risk PFO features:
  • Atrial septal aneurysm
  • Large interatrial shunt
  • Substantial right-to-left shunt 2
• Assess sinus tachycardia separately:
  • Rule out other cardiac causes (structural heart disease, heart failure)
  • Evaluate for non-cardiac causes (dehydration, anemia, hyperthyroidism, anxiety)
  • Consider 24-hour Holter monitoring to characterize the tachycardia

Risk Stratification

• Age consideration: PFO closure is primarily indicated for patients aged 18-60 years 1, 2
• Stroke history: Determine if the patient has had a cryptogenic stroke or TIA
• Evaluate for competing stroke etiologies: Rule out other causes of stroke/embolism
• Assess for deep vein thrombosis (DVT): Ultrasound examination of lower extremities to evaluate for potential source of paradoxical embolism 1

Management Algorithm

For Patients with History of Stroke/TIA

1. If patient is 18-60 years with non-lacunar cryptogenic stroke/TIA and high-risk PFO features:

   • PFO closure plus antiplatelet therapy is recommended 1, 2
   • This approach has demonstrated significant reduction in recurrent stroke rates:
     • CLOSE trial: 0% stroke rate in PFO closure group vs. 6.0% in antiplatelet-only group 2
     • REDUCE trial: 1.4% ischemic stroke rate in closure group vs. 5.4% in antiplatelet-only group 2

2. If patient is >60 years:

   • PFO closure should rarely be performed unless exceptional clinical circumstances exist 1
   • Antiplatelet therapy is generally preferred 2

3. If patient requires long-term anticoagulation for another reason:

   • Continue anticoagulation without PFO closure 2
   • Individual risk-benefit assessment should guide decision-making

For Patients without Stroke/TIA History

1. For asymptomatic PFO:

   • Antithrombotic therapy is not recommended 1
   • Monitor for symptoms and manage sinus tachycardia separately

2. For patients with evidence of paradoxical embolism (e.g., DVT with systemic embolism):

   • Consider PFO closure when technically feasible 1
   • Anticoagulation therapy is indicated until closure can be performed 3, 4

Management of Sinus Tachycardia

• Treat underlying causes (dehydration, anemia, etc.)
• Consider beta-blockers or calcium channel blockers if symptomatic and no contraindications
• Monitor for potential relationship between tachycardia and PFO-related hemodynamics

Post-PFO Closure Management

• Dual antiplatelet therapy (DAPT) for 1-3 months 5
• Followed by single antiplatelet therapy for at least 6 months 5
• Monitor for potential complications:
  • Atrial fibrillation (occurs in 4.6-6.6% of patients, mostly transient) 2
  • Device-related adverse events (approximately 1.4% of patients) 2

Important Considerations and Pitfalls

Common Pitfalls to Avoid

• Overtreatment of incidentally found PFOs without history of cryptogenic stroke
• Assuming PFO causality in older patients when it's more likely incidental
• Neglecting thorough evaluation for other stroke etiologies
• Failing to recognize that small PFOs carry lower risk than those with large shunts or associated atrial septal aneurysms 2

Special Circumstances

• Thrombus-in-transit through PFO: This is a rare but high-mortality event requiring urgent intervention, typically surgical thrombectomy with PFO closure 3, 4
• Divers and high-altitude workers: Consider PFO closure for those with history of decompression sickness, even without stroke history 2

By following this structured approach, clinicians can optimize management of patients with large PFO and sinus tachycardia, focusing on stroke prevention while addressing both conditions appropriately.