AAN: PFO closure recommended for some patients after stroke
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Closing the patent foramen ovale may be recommended in patients younger than 60 years for secondary stroke prevention, according to a practice advisory update from the American Academy of Neurology published in Neurology.
“The major takeaway is that PFO closure may be recommended for patients under 60 years of age with an embolic-appearing stroke, who have received a thorough workup and found no other potential etiologies besides the PFO,” Steven R. Messé, MD, associate professor of neurology and director of the vascular neurology fellowship at the University of Pennsylvania and a fellow of the American Academy of Neurology, told Healio. “We also recommend that physicians with expertise in stroke diagnosis and management, as well as cardiologists who are experienced with PFO closure, assess patients prior to closure to ensure appropriate patient selection.”
Review process for recommendations
This document is an update to the practice advisory released by the American Academy of Neurology (AAN) in 2016 for patients with stroke and PFO. The guideline subcommittee reviewed eight unique articles to answer questions regarding percutaneous PFO closure vs. medical therapy alone to reduce the risk for stroke recurrence in patients who have had a cryptogenic ischemic stroke and whether anticoagulation reduces this risk compared with antiplatelet medication.
“The update was prompted by the publication of three new PFO closure trials as well as additional follow-up results from one of the earlier trials, all of which showed a reduction in recurrent stroke in patients who underwent PFO closure,” Messé said in an interview. “In the prior guideline from 2016, we had concluded that PFO closure should not be routinely recommended due to a lack of strong supportive evidence and the high rate of PFO in the general population. However, with this new evidence, the major change in guidance for clinicians is that PFO closure may be recommended for select patients.”
A level B recommendation was given for clinicians to ensure that a thorough evaluation is performed in patients considered for PFO closure to rule out other mechanisms of stroke, as was done in all positive trials for PFO closure, according to the document. The authors also gave a level of recommendation if another mechanism for stroke is identified that poses a higher risk than PFO, as clinicians should not recommend closure in this patient population.
If PFO is detected after stroke with no other etiologies discovered in a thorough evaluation, clinicians should inform their patients of the prevalence of PFO — about 1 in 4 adults — and that the closure of the PFO may reduce the risk for recurrent stroke in some patients.
For patients with PFO who are younger than 60 years and have an embolic-appearing infarct as their only mechanism of stroke, PFO closure may be recommended after a discussion of potential risks (0.33% increased absolute rate of nonperiprocedural atrial fibrillation per year) and benefits (absolute risk reduction for recurrent stroke of 3.4% at 5 years), according to a level C recommendation in the document.
Another level C recommendation was given regarding clinicians recommending anticoagulation or an antiplatelet such as aspirin in patients who opt for medical therapy alone without closure of the PFO, according to the document.
Future research
Although these recommendations have been made, more research is needed in this area.
“Studies comparing direct oral anticoagulants with PFO closure in younger patients and studies comparing direct oral anticoagulants with antiplatelets in older patients and younger patients not interested in closure are warranted,” Messé and colleagues wrote. “Studies of PFO and PFO closure in the pediatric stroke population and select patients older than 60 years are also needed. Additional studies are needed to better understand anatomic characteristics that may influence the risk of stroke in patients with PFO.” – by Darlene Dobkowski
For more information:
Steven R. Messé, MD, can be reached at steven.messe@pennmedicine.upenn.edu.
Disclosures: Messé reports he received royalties from UpToDate; support from Bayer, Biogen, GlaxoSmithKline, Mallinckrodt, the NIH, Novartis and W.L. Gore and Associates, and has provided expert opinion for medical legal cases involving stroke. Please see the study for all other authors’ relevant financial disclosures.
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