The guideline subcommittee of the American Academy of Neurology (AAN) has updated practice recommendations on secondary stroke prevention and the management of patients with patent foramen ovale (PFO). The update was published in Neurology.
Current Evidence as the Basis for Recommendations
The guideline served as an update to the AAN’s practice advisory released in 2016, which provided clinical practice recommendations for secondary stroke prevention in patients with PFO. The AAN guideline subcommittee comprised a team of neurologists, internists, and cardiologists with experience and expertise in stroke and PFO. A systematic literature review was performed to identify new evidence that answered 2 key clinical questions.
The first question pertained to the role of percutaneous PFO closure in reducing stroke recurrence risk vs medical therapy only in patients with PFO who have had an otherwise cryptogenic ischemic stroke. The second question pertained to the role of anticoagulation in reducing stroke recurrence risk compared with antiplatelet therapy in this same patient population.
Based on current evidence, the guideline subcommittee suggests that percutaneous PFO closure likely reduces stroke recurrence in patients with cryptogenic stroke and PFO. The AAN subcommittee states that anticoagulation and antiplatelet medications could be equally effective in reducing recurrent stroke in these patients, according to available evidence.
Recommendation 1 Statements
In their first clinical recommendation statement, the AAN wrote that clinicians should thoroughly evaluate of patients who are being considered for PFO closure. This evaluation would help rule out alternative stroke mechanisms. The subcommittee also recommends that clinicians perform brain imaging to confirm stroke size, distribution, and the potential presence of either an embolic pattern or lacunar infarct. Complete vascular imaging should also be obtained in patients who are being considered for PFO closure. The ANN notes that vascular imaging, either MR angiography or CT angiography, should be performed on the cervical and intracranial vessels to identify dissection, atherosclerosis, or vasculopathy.
The subcommittee also recommends prolonged cardiac monitoring for 28 days or longer in patients being considered for PFO closure and who may be at risk of atrial fibrillation (AF). A baseline ECG can be used to screen for AF in these patients. A clinician who is experienced in treating stroke should perform a complete examination of the patient prior to PFO closure to ensure that PFO is the most plausible stroke mechanism. Clinicians should recommend against PFO closure if a higher-risk alternative stroke mechanism is identified.
Additionally, the guideline recommends that clinicians should assess for cardioembolic sources with transthoracic echocardiography and transesophageal echocardiography (TEE) assessment. The use of TEE would be appropriate if the first study fails to identify a high-risk stroke mechanism.
Recommendation 2 Statements
In their second series of recommendation statements, the AAN provided practice suggestions for patients over 60 years of age. The guideline states that a closure is recommended for patients in this age group who have a PFO and an embolic-appearing infarct with no other identified stroke mechanism, as long as the clinician discusses the potential benefits of the procedure. The guideline also recommends offering PFO closure in other populations, including patients between the ages of 60 to 65 years who have very few traditional vascular risk factors and no other identified stroke mechanism.
Younger patients, including those less than 30 years of age, can also receive PFO closure under the guideline recommendations if they have: a single, small; deep stroke less than 1.5 cm; a large shunt; and no evidence of vascular risk factors that would cause intrinsic small-vessel disease. The subcommittee also recommended a shared decision-making approach between patients and clinicians.
Recommendation 3 Statements
In the third series of statements, the AAN recommends the use of either antiplatelet medications or anticoagulation therapy in patients who choose to take medical therapy alone instead of PFO closure. For patients who are good candidates for PFO closure and require long-term anticoagulation because of either proven or suspected hypercoagulability, the AAN recommends that physicians counsel the patient on how the efficacy of closure and anticoagulation cannot be confirmed or discredited.
Call for Future Research
In their guideline, the AAN subcommittee wrote that additional research, including “long-term and large-scale safety registries for patients who have received PFO closure are needed to assess the risk of device erosion, fracture, embolization, and thrombotic and endocarditis risks and the effect of residual shunts and incidence of AF.”
Messé SR, Gronseth GS, Kent DM, et al. Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the guideline subcommittee of the American Academy of Neurology [published online April 29, 2020]. Neurology. doi: 10.1212/WNL.0000000000009443