What is the recommended anticoagulation therapy for menstruating women with a patent foramen ovale (PFO) and no history of stroke?

From the Guidelines

Anticoagulation therapy is not recommended for menstruating women with a patent foramen ovale (PFO) and no history of stroke, as the risks of anticoagulation generally outweigh the benefits in this population. According to the guidelines for the prevention of stroke in patients with stroke or transient ischemic attack from the American Heart Association/American Stroke Association 1, antiplatelet therapy is reasonable for patients with an ischemic stroke or TIA and a PFO, but there are insufficient data to establish whether anticoagulation is equivalent or superior to aspirin for secondary stroke prevention in patients with PFO.

Key Considerations

• The presence of a PFO in the absence of stroke or other thromboembolic events is considered an incidental finding that typically doesn't warrant anticoagulation therapy.
• The decision to anticoagulate should be individualized based on a comprehensive risk assessment that considers factors such as the presence of an atrial septal aneurysm, large shunt size, or other prothrombotic conditions.
• Management should focus on modifiable risk factors such as smoking cessation, blood pressure control, and treatment of hyperlipidemia rather than anticoagulation for primary stroke prevention in this population.

Alternative Approaches

• Aspirin 81-325 mg daily may be considered if there are other cardiovascular risk factors present, but even this is not universally recommended.
• If anticoagulation is deemed necessary due to other indications, options include direct oral anticoagulants (DOACs) like apixaban (5 mg twice daily) or warfarin (target INR 2-3), with careful monitoring of menstrual bleeding.
• The guidelines suggest that for patients with ischemic stroke or TIA and a PFO, antiplatelet therapy is reasonable, but the relative efficacy of antiplatelet therapy compared with anticoagulation is unknown 1.

Quality of Life and Safety Considerations

• The risks of anticoagulation, particularly in menstruating women who may experience heavier menstrual bleeding on such therapy, should be carefully weighed against any potential benefits.
• The guidelines emphasize the importance of individualized decision-making and consideration of the patient's overall risk profile and medical history 1.

From the Research

Anticoagulation Therapy for Menstruating Women with PFO and No History of Stroke

There are no research papers that directly address the recommended anticoagulation therapy for menstruating women with a patent foramen ovale (PFO) and no history of stroke. However, the following information can be gathered from the available studies:

• The studies primarily focus on patients with a history of stroke or atrial fibrillation, and the management of PFO in these cases 2, 3, 4, 5, 6.
• Anticoagulation therapy, such as rivaroxaban, may be considered for patients with PFO and a history of embolic stroke of undetermined source (ESUS) 4.
• A systematic review and network meta-analysis suggests that PFO closure plus antiplatelet therapy, antiplatelet therapy alone, and anticoagulation alone are management options for patients with PFO and cryptogenic stroke, but the optimal approach is uncertain 6.
• The studies do not provide specific guidance on anticoagulation therapy for menstruating women with PFO and no history of stroke, and more research is needed to determine the best approach for this population.

Key Findings

• Anticoagulation therapy may be considered for patients with PFO and a history of ESUS 4.
• PFO closure plus antiplatelet therapy, antiplatelet therapy alone, and anticoagulation alone are management options for patients with PFO and cryptogenic stroke 6.
• The optimal anticoagulation therapy for menstruating women with PFO and no history of stroke is uncertain and requires further research.

Management Options

• Antiplatelet therapy: may be considered for patients with PFO and no history of stroke, but the optimal duration and intensity of therapy are uncertain 5, 6.
• Anticoagulation therapy: may be considered for patients with PFO and a history of ESUS, but the optimal approach for menstruating women with PFO and no history of stroke is uncertain 4, 6.
• PFO closure: may be considered for patients with PFO and cryptogenic stroke, but the optimal approach and timing of closure are uncertain 6.