Can the RoPE (Risk of Paradoxical Embolism) score be applied to a 47‑year‑old hypertensive man with an incidentally discovered patent foramen ovale and no prior stroke or transient ischemic attack?

RoPE Score Application in Incidental PFO Without Prior Stroke

The RoPE (Risk of Paradoxical Embolism) score cannot and should not be applied to your patient because it was specifically designed and validated only for patients who have already experienced a cryptogenic stroke or TIA—not for asymptomatic individuals with incidentally discovered PFOs. 1, 2

Why the RoPE Score Does Not Apply

The RoPE score is a risk stratification tool that incorporates clinical characteristics (age, history of stroke/TIA, diabetes, hypertension, smoking, cortical infarct on imaging) to predict the likelihood that an already-occurred embolic stroke was caused by a PFO, not to predict future stroke risk in asymptomatic PFO patients. 2

Key Limitations in Your Patient:

• No qualifying event: The RoPE score requires a cryptogenic stroke or TIA as the index event—your patient has neither 1
• Wrong population: The score was derived from and validated in stroke patients aged 18-60 years with cryptogenic events, not in asymptomatic individuals with incidental findings 2, 3
• Misapplication of purpose: The score estimates PFO-stroke causality after the fact, not prospective stroke risk 2

What This Means for Your 47-Year-Old Patient

Current Guideline Recommendations:

No intervention is recommended for asymptomatic, incidentally discovered PFOs. 1

• The prevalence of PFO in the general population is approximately 25%, and the vast majority remain asymptomatic throughout life 2, 4
• There are no primary prevention data for patients with asymptomatic PFOs, and given the high prevalence, primary prevention studies may not be feasible 4
• Current guidelines state there is insufficient evidence to recommend PFO closure in asymptomatic individuals 1

Management Algorithm for Your Patient:

1. No closure indicated: PFO closure is not beneficial in unselected patients without stroke/TIA 1

2. Medical management:

   • Continue standard cardiovascular risk factor modification (control hypertension) 1
   • No antiplatelet or anticoagulation therapy is indicated solely for an asymptomatic PFO 1

3. No routine surveillance: Routine echocardiographic surveillance of asymptomatic PFOs is rated "Rarely Appropriate" 5

4. Patient education: Counsel that PFO is common in the general population (25%), most remain asymptomatic, and the finding does not require treatment in the absence of a thromboembolic event 1

When RoPE Score WOULD Be Appropriate

The RoPE score should only be calculated if and when this patient experiences a future cryptogenic stroke or TIA. At that point:

• A RoPE score >8 combined with high-risk PFO anatomical features (large shunt, atrial septal aneurysm) would suggest PFO closure should be considered 1
• The PASCAL classification system (which incorporates RoPE score plus echocardiographic features) would then guide closure decisions 2, 3
• Patients with RoPE scores 9-10 have 77% PFO prevalence, suggesting high likelihood of PFO-stroke causality 2

Critical Pitfall to Avoid

Do not use the RoPE score to justify prophylactic PFO closure in asymptomatic patients. This represents a fundamental misunderstanding of the tool's purpose and could expose patients to unnecessary procedural risks (including atrial fibrillation, device-related complications) without proven benefit. 1, 2

The presence of hypertension in your patient is actually a negative predictor in the RoPE score (reduces the likelihood that a stroke would be PFO-related), further emphasizing that this patient does not fit the profile for intervention even if he were to have a stroke. 2