Medical treatment
General measures
Patients with PFO who have an ischemic stroke or transient ischemic attack (TIA), who have not undergone PFO closure, should be treated with all appropriate risk reduction strategies, most importantly, antithrombotic therapy. Other measures include lifestyle modification (diet and exercise), blood pressure reduction and statins (if indicated).
Antithrombotic therapy
For most patients with an embolic-appearing cryptogenic stroke and a PFO who do not have device closure, antithrombotic therapy with antiplatelet agents is recommended¹.
Another antithrombic option is anticoagulation. However, recent trials that explored anticoagulation treatment for patients with an Embolic Stroke of Unknown Source (ESUS) were negative.² Anticoagulation is indicated for most patients with an ischemic, cryptogenic stroke and PFO who have evidence of acute deep vein thrombosis (DVT), pulmonary embolism, other venous thromboembolism (VTE) or a hypercoagulable state.
Surgical Closure of PFO
For patients aged ≤60 years who have had a cryptogenic stroke and a PFO with no other evident source of stroke and who have a concurrent indication for cardiac surgery, surgical closure of PFO via standard or minimally invasive techniques for secondary stroke prevention may be an alternative to percutaneous PFO closure.
The reported efficacy of surgical closure of a PFO in patients with prior cerebrovascular ischemic events has been variable, and randomized trials comparing surgical PFO closure with percutaneous closure or with medical therapy have not been performed.
Informed decision making
Neurologists and cardiologists should discuss consideration of the PFO closure procedure, including benefits, risks and alternative treatment options with the patient. The patient should understand the immediate and long-term potential benefits and risks of treatment options to make a well-informed decision that considers their values and preferences.
