Should a 54‑year‑old patient with an isolated patent foramen ovale and no prior stroke, transient ischemic attack, or systemic embolism be placed on chronic anticoagulation?

Anticoagulation for Isolated PFO Without Prior Stroke

No, a 54-year-old patient with an isolated PFO and no history of stroke, TIA, or systemic embolism should NOT be on chronic anticoagulation. 1

Primary Prevention: No Role for Anticoagulation

• Anticoagulation is not recommended for primary stroke prevention in patients with PFO. 1
• In healthy individuals with PFO, embolic events occur at the same frequency as in those without PFO, making primary prevention unnecessary. 2
• The 2013 ACC/AHA heart failure guidelines explicitly state that anticoagulation is not recommended in patients without atrial fibrillation, prior thromboembolic events, or a cardioembolic source. 1

PFO Closure: Also Not Indicated for Primary Prevention

• PFO closure is not recommended for primary stroke prevention. 1
• Device closure is only considered after a cryptogenic stroke has already occurred in carefully selected patients aged 18-60 years. 1, 3, 4

When Anticoagulation IS Indicated with PFO

Anticoagulation becomes appropriate only when specific high-risk conditions coexist:

• Documented venous thromboembolism or deep vein thrombosis requiring anticoagulation regardless of PFO status. 1, 4
• Atrial fibrillation with additional stroke risk factors (CHA₂DS₂-VASc score ≥1 in men, ≥2 in women). 1
• Left atrial or left ventricular thrombus demonstrated on imaging. 1
• Severe left ventricular dysfunction (EF ≤35%) with documented thrombus. 1

Critical Pitfall to Avoid

• Do not assume PFO requires treatment simply because it is present—PFOs occur in 25% of the general adult population and are typically incidental findings. 1, 5, 6
• The presence of PFO alone, without a prior embolic event, does not constitute an indication for any antithrombotic therapy beyond what would otherwise be indicated for the patient's cardiovascular risk profile. 1, 2

What This Patient Should Receive Instead

• Standard cardiovascular risk factor management (blood pressure control, lipid management, diabetes control if present, smoking cessation). 1
• No antithrombotic therapy is needed solely for the PFO. 1, 2
• Counseling that PFO is a common anatomical variant found in approximately 1 in 4 adults and does not require treatment in the absence of a stroke or other specific indication. 5, 6