New Advisory Update Recommends PFO Closure for Stroke Patients

May 1, 2020

The AAN has released an update to their 2016 practice advisory—changing their stance on PFO closure to reduce risk of second stroke.

In an effort to improve patient care and outcomes, the American Academy of Neurology has released new guidance for clinicians treating patients with stroke and patent foramen ovale (PFO).

Originally released in 2016, the new update recommends closure of PFO in some patients aged 60 years and older—a change the AAN noted is a result of evidence released since publication of the 2016 recommendations.

"It's 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," said lead author Steven R. Messé, MD, associate professor of neurology at Perelman School of Medicine at the University of Pennsylvania and a fellow of the American Academy of Neurology, in a statement. "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."

Endorsed by other organizations including the American Heart Association/American Stroke Association, the Society for Cardiovascular Angiography and Interventions and the European Academy of Neurology, the 11-page document was created by Messé and 9 other members of the AAN’s Guideline Subcommittee. Committee members conducted a systematic review of MEDLINE and the Cochrane Library to determine if percutaneous PFO closure reduces risk of stroke recurrence more than medical therapy alone in patients with a PFO who have had a cryptogenic ischemic stroke and if anticoagulation reduced risk of stroke recurrence compared with antiplatelet medication in the same patient population.

A total of 628 randomized trials were identified by committee members, of which 8 met inclusion criteria. Of note, 1 of the 8 was a follow-up study from a trial included in the 2016 practice advisory.

Briefly, the 2016 advisory from the AAN concluded there was insufficient cement evidence to support a recommendation for routine PFO closure to prevent a second stroke—new data included in the update has altered that stance.

According to the practice advisory, doctors may recommend closure of PFO, after discussing the benefits and risks, in patients younger than 60 who have had a stroke thought to be caused by PFO and no other cause. Based on the committee’s review of data, PFO closure in these patients reduces risk of second stroke in 5 years. The advisory also highlighted a 3.9% absolute risk of procedural complications and an 0.33% increased risk of atrial fibrillation per year.

The advisory stresses the importance of ruling out potential causes of stroke other than PFO and recommends that patients considering closure have a consultation with an expert in PFO closure to ensure it can be safely performed. There is no recommendation for PFO closure if another high-risk cause of stroke is identified.

“The risk of a second stroke in people with PFO and no other possible causes of stroke is very low, approximately 1% per year while being treated with just medication alone,” said Messé. “Also, it is difficult to determine with absolute certainty that the PFO is the cause of a person’s stroke. So it is important that people with PFO are educated about the benefits and risks of PFO closure.”

In patients who opt to take medications alone and not undergo PFO closure, the doctors may consider prescribing aspirin other antiplatelet or anticoagulant drugs such as warfarin to prevent blood clots, according to the updated advisory.

This article, “Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology,” was published in Neurology.