Patent foramen ovale medical therapy: Difference between revisions
/* American Academy of Neurology Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT){{cite journal| author=Messé SR, Silverman IE, Kizer JR, Homma S, Zahn C, Gronseth G et al.| title=Practice parameter: recur... |
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'''Practice Recommendations''' | '''Practice Recommendations''' | ||
1) There is insufficient evidence in determining the | 1) There is insufficient evidence in determining the efficacy of anticoagulants compared with antiplateles in preventing reccurent strokes in patients with crptogenic stroke and patent foramen ovale. Thereby, clinicians may routinely offer antiplatelet medications instead of anticoagulants to patients with PFO and cryptogenic shock with no other indication for anticoagulants (e.g deep venous thrombosis). | ||
2) Among patients with a [[Paradoxical embolism|cryptogenic stroke]] and atrial septal abnormalities, there is insufficient evidence to determine the superiority of [[aspirin]] or [[warfarin]] for prevention of recurrent [[stroke]] or death '''(Level U)''', but the risks of minor [[bleeding]] are possibly greater with [[warfarin]] '''(Level C)''' | 2) Among patients with a [[Paradoxical embolism|cryptogenic stroke]] and atrial septal abnormalities, there is insufficient evidence to determine the superiority of [[aspirin]] or [[warfarin]] for prevention of recurrent [[stroke]] or death '''(Level U)''', but the risks of minor [[bleeding]] are possibly greater with [[warfarin]] '''(Level C)''' | ||
Revision as of 18:59, 3 February 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [3]
Overview
The medical therapy for the patients with patent foramen ovale is controversial. Medical therapy with antiplatelet therapy (aspirin) or anticoagulant therapy (warfarin) could be considered in patients with recurrent strokes after index episode of cryptogenic stroke and unresponsive migraines. However, the relative effectiveness of aspirin or warfarin in these patients has not been proved.
Medical Therapy
There is a lack of consensus on the medical therapy for patent foramen ovale. Asymptomatic patent foramen ovale doesn't warrant any treatment. The incidence of recurrent stroke in patients with index episode of cryptogenic stroke and treated with aspirin or warfarin has been found similar in presence or absence of a patent foramen ovale[1]. However, an increased risk of subsequent stroke has been seen in patent foramen ovale associated with atrial septal aneurysm. Thus, treatment with aspirin or warfarin could be considered in patients with patent foramen ovale associated with atrial septal abnormalities or other complicated patent foramen ovale. There are lack of studies to compare the efficacy of aspirin and warfarin in these conditions. However, aspirin's safety profile has been found to be better than warfarin (less bleeding). The benefit of PFO closure is not well established in the patient with a cryptogenic stroke. The benefit of coumadin in the patient with PFO is not well established, and this therapy should be reserved for those patients with atrial fibrillation or venous thromboembolism.
Supportive Trial Data
A large randomized multicenter trial (42 centers) was done to compare the relative efficacy of aspirin and warfarin to prevent recurrent strokes in patients with patent foramen ovale[1]. The study found an increased incidence of patent foramen ovale with cryptogenic stroke. This was similar to the results found in previous small scale trials [2][3][4]. Also, it was found in the study that cryptogenic strokes were commoner in larger patent foramen ovale compared to the smaller. Nevertheless, the rate of recurrent stroke or death, in medically treated patients after index episode of cryptogenic stroke, was found to be similar between patients with and without patent foramen ovale. Also, the rate of adverse events after medical therapy was found to be the same in patent foramen ovale of different size.
International Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale
American Academy of Neurology Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[5][6]
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Practice Recommendations 1) There is insufficient evidence in determining the efficacy of anticoagulants compared with antiplateles in preventing reccurent strokes in patients with crptogenic stroke and patent foramen ovale. Thereby, clinicians may routinely offer antiplatelet medications instead of anticoagulants to patients with PFO and cryptogenic shock with no other indication for anticoagulants (e.g deep venous thrombosis). 2) Among patients with a cryptogenic stroke and atrial septal abnormalities, there is insufficient evidence to determine the superiority of aspirin or warfarin for prevention of recurrent stroke or death (Level U), but the risks of minor bleeding are possibly greater with warfarin (Level C) |
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Rating of Recommendations
A = Established as effective, ineffective, or harmful for the given condition in the specified population.
B = Probably effective, ineffective, or harmful for the given condition in the specified population.
C = Possibly effective, ineffective, or harmful for the given condition in the specified population.
U = Data inadequate or conflicting. Given current knowledge, treatment (test, predictor) is unproven.
American Academy of Chest Physicians Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT) [7]
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1) In patients with cryptogenic ischemic stroke and a PFO, we recommend antiplatelet therapy over no therapy (Grade 1A) and suggest antiplatelet therapy over warfarin (Grade 2A). 2) For patients with evidence of a DVT, anticoagulation therapy is recommended. |
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American Heart Association/American Stroke Association Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[8]
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1) Antiplatelet therapy reasonable. 2) Warfarin reasonable for high-risk patients with other indications such as hypercoagulable state or venous thrombosis. |
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European Stroke Organisation Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[9]
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1) Patients with cardioembolic stroke unrelated to atrial fibrillation should receive warfarin if the risk of recurrence is high. |
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References
- ↑ 1.0 1.1 Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptographic Stroke Study (PICSS) Investigators (2002). "Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study". Circulation. 105 (22): 2625–31. PMID 12045168.
- ↑ Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M; et al. (1988). "Prevalence of patent foramen ovale in patients with stroke". N Engl J Med. 318 (18): 1148–52. doi:10.1056/NEJM198805053181802. PMID 3362165.
- ↑ Webster MW, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM; et al. (1988). "Patent foramen ovale in young stroke patients". Lancet. 2 (8601): 11–2. PMID 2898621.
- ↑ Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S (1992). "Patent foramen ovale as a risk factor for cryptogenic stroke". Ann Intern Med. 117 (6): 461–5. PMID 1503349.
- ↑ Messé SR, Silverman IE, Kizer JR, Homma S, Zahn C, Gronseth G; et al. (2004). "Practice parameter: recurrent stroke with patent foramen ovale and atrial septal aneurysm: report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 62 (7): 1042–50. PMID 15078999.
- ↑ Messé, Steven R.; Gronseth, Gary; Kent, David M.; Kizer, Jorge R.; Homma, Shunichi; Rosterman, Lee; Kasner, Scott E. (2016). "Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter)". Neurology. 87 (8): 815–821. doi:10.1212/WNL.0000000000002961. ISSN 0028-3878.
- ↑ Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P (2004). "Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy". Chest. 126 (3 Suppl): 483S–512S. doi:10.1378/chest.126.3_suppl.483S. PMID 15383482.
- ↑ Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC; et al. (2011). "Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association". Stroke. 42 (1): 227–76. doi:10.1161/STR.0b013e3181f7d043. PMID 20966421.
- ↑ European Stroke Organisation (ESO) Executive Committee. ESO Writing Committee (2008). "Guidelines for management of ischaemic stroke and transient ischaemic attack 2008". Cerebrovasc Dis. 25 (5): 457–507. doi:10.1159/000131083. PMID 18477843.