AAN Updates Recommendation on Closure of Patent Foramen Ovale After Stroke

May 1, 2020
New guidance from the American Academy of Neurology (AAN) recommends closure of a patent foramen ovale (PFO) for some patients who have had a stroke. The updated practice advisory is published in the online issue of the journal Neurology. Closure may be considered for some people aged younger than 60 years to help prevent a second stroke, according to the practice advisory, which is endorsed by the American Heart Association/American Stroke Association, the Society for Cardiovascular Angiography and Interventions, and the the European Academy of Neurology. “It’s important to note that having a PFO is common, and that most people with PFO will never know they have it because it usually does not cause any problems,” said Steven R. Messé, MD, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. “However, while there is generally a very low risk of stroke in patients with PFO, in younger people who have had a stroke without any other possible causes identified, closing the PFO may reduce the risk of having another stroke better than medication alone.” The practice advisory updates a 2016 advisory that concluded there was not enough evidence to support routine PFO closure to prevent a second stroke. Since then, new studies reported that for people with stroke due to a PFO, closure in addition to anticoagulation medication, reduced the risk of future strokes better than medication alone. For the practice advisory, clinical experts carefully reviewed the available evidence about stroke prevention in patients with a PFO who had already had an ischaemic stroke. When considering PFO closure in people who have had a stroke, the practice advisory recommends that doctors with expertise in stroke to first rule out causes other than the PFO, such as hardening or a tear of the blood vessels, heart disease including abnormal heart rhythms, or an increased risk for forming clots, to ensure that PFO is the most likely cause of stroke. The practice advisory does not recommend PFO closure if another higher risk cause of stroke is identified. The advisory also recommends that patients considering closure have a consultation with an expert in PFO closure, to ensure that the procedure can be safely performed. “The risk of a second stroke in people with PFO and no other possible causes of stroke is very low, approximately 1% per year while being treated with just medication alone,” said Dr. Messé. “Also, it is difficult to determine with absolute certainty that the PFO is the cause of a person’s stroke. So it is important that people with PFO are educated about the benefits and risks of PFO closure.” For patients who choose to take medications alone, without PFO closure, doctors may consider prescribing aspirin or other antiplatelet drugs or blood thinners. Reference: https://n.neurology.org/lookup/doi/10.1212/WNL.0000000000009443 SOURCE: American Academy of Neurology