What is the next step for a patient with a patent foramen ovale (PFO) who has suffered a stroke and developed deep vein thrombosis (DVT)?

Management of PFO with Stroke and Concurrent DVT

This patient requires anticoagulation therapy for at least 3 months to treat the DVT, with consideration for PFO closure after the acute thrombotic event is managed. 1

Immediate Management Priority

The presence of concurrent DVT fundamentally changes the management approach from a typical cryptogenic stroke with PFO. This patient has a clear thrombotic source (DVT) that likely caused paradoxical embolism through the PFO, making this a high-risk scenario rather than a simple cryptogenic stroke. 1

Anticoagulation is Mandatory

• Warfarin (target INR 2.0-3.0) should be initiated immediately for a minimum of 3 months to treat the documented DVT, which is the standard treatment duration for provoked venous thromboembolism. 1

• The American College of Chest Physicians specifically recommends vitamin K antagonist therapy for patients with cryptogenic stroke, DVT, and PFO. 1

• The American Heart Association guidelines classify this as a "high-risk" scenario where warfarin is reasonable for patients with cryptogenic stroke and PFO who have evidence of venous thrombosis (Class IIa recommendation). 1

Role of PFO Closure

PFO closure should be considered after completing the initial anticoagulation course for DVT. 1

• The presence of DVT with PFO increases the risk of death 10-fold and arterial thromboembolism 5-fold, making this a particularly high-risk anatomic substrate. 2

• PFO closure is not indicated as primary therapy for first stroke events in typical cases, but the concurrent DVT represents a documented mechanism for paradoxical embolism, which changes the risk-benefit calculation. 1

• The American College of Chest Physicians suggests consideration of PFO closure (Grade 2C) in patients with cryptogenic stroke, DVT, and PFO after the acute thrombotic phase is managed. 1

Critical Clinical Reasoning

The key distinction here is that this is not a simple cryptogenic stroke—the DVT provides a clear embolic source and mechanism (paradoxical embolism). This documented pathway of venous thrombus → PFO → arterial circulation makes the case for both anticoagulation and eventual closure stronger than in typical PFO-associated stroke. 3

Workup for Hypercoagulable State

• Because there may be an increased incidence of hypercoagulable disorders among patients with PFO who have stroke, evidence of a hypercoagulable disorder should be sought. 1

• If a thrombophilia is identified, this would further support long-term anticoagulation beyond the initial 3-month treatment period. 1

Treatment Algorithm

1. Immediate phase (Days 0-7):

   • Initiate therapeutic anticoagulation with bridging unfractionated heparin or low-molecular-weight heparin while transitioning to warfarin (target INR 2.0-3.0). 1
   • Complete hypercoagulable workup. 1

2. Acute phase (Months 1-3):

   • Continue warfarin for minimum 3 months to treat DVT. 1
   • Evaluate for PFO closure candidacy if patient is under 60 years old. 4, 5, 2

3. Post-acute phase (After 3 months):

   • If no hypercoagulable state identified and DVT was provoked, consider PFO closure with transition to antiplatelet therapy. 1
   • If hypercoagulable state identified, continue long-term anticoagulation and reassess need for PFO closure. 1

Common Pitfalls to Avoid

• Do not discharge without anticoagulation—the DVT requires treatment regardless of PFO management decisions. 1

• Do not close PFO acutely—the active thrombotic state is a relative contraindication to device placement; closure should be deferred until after completing DVT treatment. 1

• Do not use aspirin alone—this patient has a documented venous thrombosis requiring full anticoagulation, not just antiplatelet therapy. 1

• Do not assume this is typical cryptogenic stroke—the concurrent DVT provides a clear mechanism and mandates different management than isolated PFO with stroke. 3