What is the management of a patient with bilateral ischemic strokes and a patent foramen ovale (PFO) diagnosed on transesophageal echocardiogram (TEE)?

Management of a 68-Year-Old Female with Bilateral Ischemic Strokes and PFO

For a 68-year-old female with bilateral ischemic strokes found to have a PFO on TEE, antiplatelet therapy is recommended as the first-line treatment rather than PFO closure, as the benefits of closure are not established in patients over 60 years of age. 1

Initial Assessment and Risk Stratification

• PFO is present in approximately 25% of all adults and may be an incidental finding rather than the cause of stroke, especially in older patients with vascular risk factors 2
• Evaluate for other potential causes of stroke, as PFO is less likely to be causative in patients over 60 years of age 1, 2
• Consider using the Risk of Paradoxical Embolism (RoPE) score and PFO-Associated Stroke Causal Likelihood (PASCAL) classification to determine the likelihood that the stroke was caused by the PFO 2
• Older age (68 years) significantly reduces the probability that the PFO is causative rather than incidental 2

Medical Therapy Options

Antiplatelet Therapy

• Antiplatelet therapy is the recommended first-line treatment for patients with ischemic stroke and PFO who are over 60 years of age 1
• Options include:
  • Aspirin (75-325 mg daily) 1
  • Clopidogrel (75 mg daily) if aspirin is not tolerated 1
  • Combination of aspirin (25 mg) plus sustained-release dipyridamole (200 mg) twice daily 1

Anticoagulation Therapy

• Consider anticoagulation therapy if there are additional risk factors such as:
  • Evidence of venous thrombosis 1
  • Hypercoagulable state 1
  • Recurrent ischemic events despite antiplatelet therapy 1
• Warfarin with target INR of 2.0-3.0 is recommended if anticoagulation is indicated 1, 3
• Direct oral anticoagulants (DOACs) may be considered as an alternative to warfarin, though evidence specifically for PFO is limited 1

PFO Closure Considerations

• PFO closure is generally NOT recommended for patients over 60 years of age with cryptogenic stroke 1, 2
• The benefits of PFO closure have been demonstrated primarily in patients under 60 years of age 1, 4, 2
• In the RESPECT trial, PFO closure was associated with a lower rate of recurrent ischemic strokes compared to medical therapy alone (HR 0.55; 95% CI, 0.31-0.999) but the mean age of patients was 45.9 years 4
• Risks of PFO closure include:
  • Device or procedure-related adverse events (3.6% absolute risk) 1
  • Increased risk of persistent atrial fibrillation (1.8% absolute risk increase) 1
  • Transient atrial fibrillation (1.2% absolute risk increase) 1

Follow-up and Monitoring

• Regular follow-up to monitor for recurrent stroke or TIA symptoms 5
• Assess medication adherence and tolerance 1
• Consider periodic cardiovascular risk factor assessment and management 2
• If recurrent events occur despite medical therapy, reevaluate the treatment approach and consider alternative options 1

Special Considerations

• If the patient has concurrent atrial fibrillation, anticoagulation would be indicated regardless of PFO status 1
• For patients with bilateral strokes, consider more extensive evaluation for other potential embolic sources 1
• Advise patients to avoid activities that may increase right-to-left shunting (e.g., Valsalva maneuvers) 1
• Consider evaluation for deep vein thrombosis as a potential source of paradoxical embolism 1, 3