New guidance from the American Academy of Neurology (AAN) recommends the closure of a patent foramen ovale (PFO) for some people who have had a stroke. The updated practice advisory has been published online in Neurology. Previous guidance concluded there was not enough evidence to support routine PFO closure to prevent a second stroke.
The new guidance states that PFO closure may be considered for some people under age 60 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 European Academy of Neurology.
It updates a 2016 advisory, which said that there was not enough evidence to support routine PFO closure to prevent a second stroke. However, since then, new studies reported that for people with stroke due to a PFO, closure in addition to taking medication to prevent blood clots, reduced the risk of future strokes better than medication alone.
Therefore, the new guidance recommends that when considering PFO closure in people who have had a stroke, 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—to ensure that PFO is the most likely cause of stroke; it does not recommend PFO closure if another higher risk cause of stroke is identified.
Furthermore, the guidance states that for people younger than 60 years’ old who have had a stroke thought to be caused by a PFO and no other cause, doctors may recommend closure of the PFO after discussing the potential benefits. These benefits include a 3.4% reduction in the risk of a second stroke in five years, as well as the potential risks, such as a 3.9% chance of procedural complications and an increased risk of an abnormal heart rhythm called atrial fibrillation of 0.33% per year.
Lead author Steven R Messé (Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA), says: “It is 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. 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.”