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Updated: Apr 28, 2026
Closure of a Patent Foramen Ovale PFO: An Intervention Sequence
Published on: December 23, 2022
Recurrent stroke predictors differ in medically treated patients with pathogenic vs. other PFOs
David E Thaler1, Robin Ruthazer2, Christian Weimar2
1From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland. dthaler@tuftsmedicalcenter.org.
Objective:
To examine predictors of stroke recurrence in patients with a high vs a low likelihood of having an incidental patent foramen ovale (PFO) as defined by the Risk of Paradoxical Embolism (RoPE) score.
Methods:
Patients in the RoPE database with cryptogenic stroke (CS) and PFO were classified as having a probable PFO-related stroke (RoPE score of >6, n = 647) and others (RoPE score of ≤6 points, n = 677). We tested 15 clinical, 5 radiologic, and 3 echocardiographic variables for associations with stroke recurrence using Cox survival models with component database as a stratification factor. An interaction with RoPE score was checked for the variables that were significant.
Results:
Follow-up was available for 92%, 79%, and 57% at 1, 2, and 3 years. Overall, a higher recurrence risk was associated with an index TIA. For all other predictors, effects were significantly different in the 2 RoPE score categories. For the low RoPE score group, but not the high RoPE score group, older age and antiplatelet (vs warfarin) treatment predicted recurrence. Conversely, echocardiographic features (septal hypermobility and a small shunt) and a prior (clinical) stroke/TIA were significant predictors in the high but not low RoPE score group.
Conclusion:
Predictors of recurrence differ when PFO relatedness is classified by the RoPE score, suggesting that patients with CS and PFO form a heterogeneous group with different stroke mechanisms. Echocardiographic features were only associated with recurrence in the high RoPE score group.
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