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Closure of a Patent Foramen Ovale PFO: An Intervention Sequence
Published on: December 23, 2022
Determinants of antithrombotic choice for patent foramen ovale in cryptogenic stroke
David E Thaler1, Robin Ruthazer2, Christian Weimar2
1From the Department of Neurology (D.E.T., D.M.K.), and Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; Department of Neurology, University of Duisburg-Essen (C.W.), Germany; Neurology Department at the Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona (J.S.), Spain; Department of Neurology, Inselspital (H.P.M., M.-L.M.), University of Bern; Division of Neurology at the Triemli Municipal Hospital (K.N.), Zurich, Switzerland; Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; Departments of Neurology and Epidemiology (M.S.V.E.), and Division of Cardiology (M.R.D.T., S.H.), Columbia University, NY; Neurology Service, Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland; Department of Cardiology (B.M.), Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland; and Department of Neurology (A.J.F.), Case Western Reserve University, Cleveland, OH. dthaler@tuftsmedicalcenter.org.
Insights
In cryptogenic stroke (CS) patients with patent foramen ovale (PFO), specific imaging findings, not age or risk factors, influenced antithrombotic choice. This suggests imaging guides treatment decisions for stroke prevention.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Cryptogenic stroke (CS) with patent foramen ovale (PFO) presents a diagnostic and therapeutic challenge.
- Antithrombotic therapy choice (anticoagulation vs. antiplatelets) is critical for secondary stroke prevention.
- Understanding factors influencing treatment selection is key to optimizing patient outcomes.
Purpose of the Study:
- To investigate the impact of clinical, radiologic, and echocardiographic characteristics on antithrombotic selection in CS patients with PFO.
- To determine if features suggesting paradoxical embolism influence the choice between anticoagulation and antiplatelet therapy.
Main Methods:
- Utilized the Risk of Paradoxical Embolism Study, combining 12 databases for a large CS and PFO patient cohort.
- Employed generalized linear mixed models to analyze the association between patient/imaging characteristics and antithrombotic choice.
- Assessed influence of age, vascular risk factors, high-risk echocardiographic features, and neuroradiologic findings.
Main Results:
- Included 1,132 patients; 39% received anticoagulation.
- Treatment choice was not associated with age or vascular risk factors.
- Neoradiologic findings (superficial/multiple infarcts) and high-risk echocardiographic features (large shunts, shunt at rest, septal hypermobility) predicted anticoagulation use.
Conclusions:
- Both anticoagulation and antiplatelet therapies are commonly used for secondary stroke prevention in CS with PFO.
- Radiologic and echocardiographic findings significantly influenced antithrombotic choice.
- Conventional vascular risk factors did not impact treatment selection, suggesting prior studies may have confounding by indication.
Objective:
We examined the influence of clinical, radiologic, and echocardiographic characteristics on antithrombotic choice in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), hypothesizing that features suggestive of paradoxical embolism might lead to greater use of anticoagulation.
Methods:
The Risk of Paradoxical Embolism Study combined 12 databases to create the largest dataset of patients with CS and known PFO status. We used generalized linear mixed models with a random effect of component study to explore whether anticoagulation was preferentially selected based on the following: (1) younger age and absence of vascular risk factors, (2) "high-risk" echocardiographic features, and (3) neuroradiologic findings.
Results:
A total of 1,132 patients with CS and PFO treated with anticoagulation or antiplatelets were included. Overall, 438 participants (39%) were treated with anticoagulation with a range (by database) of 22% to 54%. Treatment choice was not influenced by age or vascular risk factors. However, neuroradiologic findings (superficial or multiple infarcts) and high-risk echocardiographic features (large shunts, shunt at rest, and septal hypermobility) were predictors of anticoagulation use.
Conclusion:
Both antithrombotic regimens are widely used for secondary stroke prevention in patients with CS and PFO. Radiologic and echocardiographic features were strongly associated with treatment choice, whereas conventional vascular risk factors were not. Prior observational studies are likely to be biased by confounding by indication.
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