Management of patent foramen ovale in patients with stroke history: AAN Guideline
Written By : Medha Baranwal
Medically Reviewed By : Dr. Kamal Kant Kohli
Published On 2021-01-13 05:40 GMT | Update On 2021-01-13 05:40 GMT
- In patients younger than 60 years with a PFO and an embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (reduction of stroke recurrence) and risks (procedural complication and atrial fibrillation).
- Clinicians may inform patients that presence of a large shunt probably is associated with benefit from closure. Conversely, there probably is less likelihood of benefit in patients with a small shunt or a non–embolic-appearing single, small, deep infarct, and it is uncertain whether atrial septal aneurysm in the absence of a large shunt influences the likelihood of benefitting from PFO closure.
- PFO closure may be offered in other populations, such as for a patient who is aged 60–65 years with a very limited degree of traditional vascular risk factors (i.e., hypertension, diabetes, hyperlipidemia, or smoking) and no other mechanism of stroke detected following a thorough evaluation, including prolonged monitoring for atrial fibrillation.
- PFO closure may be offered to younger patients (e.g., <30 years) with a single, small, deep stroke (<1.5 cm), a large shunt, and absence of any vascular risk factors that would lead to intrinsic small-vessel disease such as hypertension, diabetes, or hyperlipidemia.
- In a patient for whom PFO closure is being considered, a shared decision-making approach between clinicians and the patient should be used, exploring how well the patient's attributes match those included in the positive PFO closure trials and the patient's preferences and concerns regarding risk of stroke recurrence and risk of adverse events.
- In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend either an antiplatelet medication such as aspirin or anticoagulation (using a vitamin K antagonist, a direct thrombin inhibitor, or a factor Xa inhibitor).
- In patients who would otherwise be considered good candidates for PFO closure but require long-term anticoagulation because of suspected or proven hypercoagulability (defined thrombophilia, unprovoked deep venous thrombosis, or unprovoked pulmonary embolism), clinicians should counsel the patient that the efficacy of PFO closure in addition to anticoagulation cannot be confirmed or refuted.
"Management of Patients With a Patent Foramen Ovale With History of Stroke or TIA," is published in the journal JAMA.
DOI: https://jamanetwork.com/journals/jama/article-abstract/2774671
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