Version June 2024
This algorithm is intended to provide general guidance to PFO management in patients with a recent embolic-appearing ischemic stroke who have a PFO and no other identified cause of stroke. For most patients who are ≤60 years of age with a possible, probable, or definite likelihood by RoPE and PASCAL that the PFO was causally associated with the stroke, we suggest percutaneous PFO device closure in addition to antiplatelet therapy. PFO device closure may be temporarily deferred for patients with an indication for short-term anticoagulation. The benefit of PFO device closure is uncertain for patients >60 years of age and for patients with an indication for long-term anticoagulation; in such cases, an individualized approach with shared decision-making is appropriate. Patients with ischemic stroke should generally be treated with all available risk reduction strategies including antithrombotic therapy, blood pressure control, low-density lipoprotein (LDL)-lowering therapy, and lifestyle modification, as appropriate.
For details regarding the evaluation required for a comprehensive stroke evaluation, choice of antithrombotic therapy, and other factors that impact decision-making for PFO management, refer to appropriate UpToDate topics.PFO: patent foramen ovale; DVT: deep venous thrombosis; PE: pulmonary embolism; RoPE: Risk of Paradoxical Embolism; PASCAL: PFO-associated stroke causal likelihood; ASA: atrial septal aneurysm.
* For most patients with an indication for anticoagulation >1 year, PFO closure is not performed, as benefit in this setting is uncertain. PFO closure may be an option for selected patients, such as those who experience recurrent embolic stroke without other identified cause while therapeutically anticoagulated and those who are no longer anticoagulated. An individualized approach to decision-making is based upon patient preferences, risk factors, and comorbidities.
¶ Patients who undergo PFO closure (percutaneous or surgical) are treated with antiplatelet agents. We treat with aspirin (75 to 81 mg/day) plus clopidogrel (75 mg/day) for three months, followed by continued aspirin therapy.
Δ For the rare patient who has a concurrent indication for surgical valve intervention, surgical (rather than percutaneous) PFO closure is appropriate. If percutaneous PFO closure is not feasible and there is no concurrent indication for cardiac surgery, we suggest against surgical PFO closure.
◊ For most patients >60 years old, PFO closure is not performed since such patients were excluded from trials of PFO closure and the benefit of closure in this setting is unproven. PFO closure may be an option for selected patients >60 years old, such as younger patients in this age range who have low estimated atherosclerotic cardiovascular disease risk. An individualized approach to decision-making is based upon patient preferences, risk factors, and comorbidities.
§ Refer to UpToDate topic on cryptogenic stroke.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
