What should I do about my large patent foramen ovale (PFO) and worsening symptoms, including arm weakness and POTS symptoms, given my cardiologist's refusal to treat or monitor?

From the Guidelines

I strongly recommend seeking a second opinion from another cardiologist immediately, as your symptoms of arm weakness, chest pressure, dizziness, and history of a mini stroke with a large PFO warrant urgent evaluation. In the meantime, consider calling your primary care physician to document these symptoms and ask for assistance in expediting a referral to a different cardiologist who specializes in structural heart conditions, as PFOs can sometimes require closure procedures to prevent recurrent strokes, especially in patients who have already experienced neurological symptoms, as supported by the 2021 guideline from the American Heart Association/American Stroke Association 1 and the Canadian Stroke Best Practice Recommendations 1.

From the Research

Patient Concerns and Cardiologist's Policy

The patient's concerns about their cardiologist's policy to wait for a serious life-threatening event before taking action are valid, given their ongoing worsening symptoms, including sudden weakness, pressure and cramping in the chest, dizziness, and other POTS symptoms 2, 3. The patient's experience of having a mini-stroke as a reaction to the bubble study and being diagnosed with a large PFO suggests that their condition may require more urgent attention and monitoring.

Potential Courses of Action

• The patient may want to consider seeking a second opinion from a dedicated cardiologist experienced in the management of cardioembolism, as recommended in the national consensus statement on the assessment of patients with suspected cardioembolic ischemic stroke 2.
• The patient's symptoms and medical history suggest that they may benefit from a more comprehensive evaluation and management plan, including potential referral to an advanced heart failure center or a neurologist specializing in stroke care 4, 5.
• The patient's primary care physician or another healthcare provider may be able to provide guidance on navigating the healthcare system and advocating for more timely and appropriate care, using a framework such as the 5As model for counseling patients at risk for cardiovascular disease 6.