What is the next step in managing an 84-year-old patient with stroke-like symptoms, a patent foramen ovale (PFO) diagnosed by agitated saline imaging on echocardiogram (echo), and Alzheimer's dementia?

Management of an 84-Year-Old Patient with Stroke-Like Symptoms, PFO, and Alzheimer's Dementia

For an 84-year-old patient with stroke-like symptoms, patent foramen ovale (PFO), and Alzheimer's dementia, antiplatelet therapy alone is recommended as the most appropriate management strategy rather than PFO closure or anticoagulation.

Age-Based Considerations

• PFO closure is not recommended for patients over 60 years of age with stroke-like symptoms, as the benefits of closure are significantly smaller and the harms potentially greater in this population 1, 2
• In older patients (>60 years), fewer cryptogenic strokes are caused by paradoxical emboli through a PFO, making the causal relationship between PFO and stroke less likely 1
• Current guidelines specifically state that PFO closure is not recommended for patients with stroke who are aged >60 years 1

Evidence for Treatment Selection in Older Adults

• Antiplatelet therapy is the recommended first-line treatment for patients over 60 years with ischemic stroke and PFO 2
• Options include aspirin (75-325 mg daily), clopidogrel (75 mg daily), or a combination of aspirin and dipyridamole 2
• The benefits of PFO closure have been demonstrated primarily in patients under 60 years of age in clinical trials, with limited evidence in older populations 2, 3
• A recent analysis of PFO closure in older adults suggests that the anticipated effect sizes would be much smaller than in younger patients, requiring substantially larger clinical trials to demonstrate benefit 4

Risk-Benefit Assessment

• Risks of PFO closure include:
  • Device or procedure-related adverse events (3.6% absolute risk) 2
  • Increased risk of persistent atrial fibrillation (1.8% absolute risk increase) 2
  • Transient atrial fibrillation (1.2% absolute risk increase) 2
• These risks are particularly concerning in an 84-year-old patient with Alzheimer's dementia, where procedural complications and post-procedure management may be more challenging 1
• The PASCAL classification system, which combines clinical and anatomical features to determine the likelihood that a PFO caused a stroke, would likely categorize this patient in the "unlikely" category due to advanced age 3, 5
• Patients in the "unlikely" PASCAL category showed no benefit from PFO closure but had higher risks of procedure-related adverse events 5

Considerations for Patients with Dementia

• The presence of Alzheimer's dementia adds complexity to management decisions, as:
  • Procedural risks may be higher due to challenges with cooperation during and after the procedure 2
  • Anticoagulation management may be more difficult due to potential medication adherence issues 2
  • The overall risk-benefit ratio must consider reduced life expectancy and quality of life impacts 1

Follow-up Recommendations

• Regular assessment of medication adherence and tolerance 2
• Monitoring for recurrent stroke symptoms 2
• If recurrent events occur despite antiplatelet therapy, reevaluation of the treatment approach may be warranted 2
• Consider evaluation for other potential sources of stroke, including atrial fibrillation, which is common in this age group 2, 5

Key Pitfalls to Avoid

• Assuming that PFO is the cause of stroke-like symptoms in an elderly patient without ruling out other more common causes in this age group 1, 2
• Pursuing invasive PFO closure in an elderly patient with dementia when evidence suggests limited benefit and increased risks 1, 2
• Failing to consider the patient's overall health status, life expectancy, and quality of life when making treatment decisions 1