Stroke Prevention in Patients with Patent Foramen Ovale

Patent foramen ovale closure versus drug therapy in patients over 60 years and a follow-up of 5 years

BACKGROUND

The advantages of patent foramen ovale (PFO) closure as protection from a recurrence of stroke remains controversial compared to drug therapy, especially in patients over 60 years.

HYPOTHESIS

The aim of the study is to compare recurrence of stroke in patients over 60 years old with PFO closure versus drug therapy alone.

METHODS

We included 342 patients over 60 years who suffered a crytopgenic stroke, and were also accepted for a PFO closure. 199 patients refused a PFO closure and were treated with medical therapy alone, whereas 143 patients underwent a PFO closure procedure.

RESULTS

The mean follow up time was 5.5 ± 1.5 years. All patients in Group B showed persistent shunt in the follow-up period (n = 199, 100%). In Group A, seven patients were diagnosed with residual shunt during echocardiography examination (5%). A new onset of atrial fibrillation occurred in seven patients in Group A (5%) and six patients in Group B (3%), p = .117. Recurrent stroke occurred in 3 patients in Group A (2%) and 11 patients in Group B (6%), p = .021. One patient died of unknown reason (1%) and two patients were lost due to neurological death (1%) in Group B, whereas no patients in Group A died during the follow-up period.

CONCLUSION

Our results show that strict exclusion of patients over 60 years from PFO closure should be reconsidered. As life expectancies are increasing, patients should be considered for same treatment as younger patients, since the outcomes are improved compared to patients treated with medical therapy alone.

Diagnosis and Management of Cardioembolic Stroke

OBJECTIVE

Cardioembolic stroke accounts for nearly 30% of ischemic strokes. Prompt diagnosis of the underlying mechanism may improve secondary prevention strategies. This article reviews recent randomized trials, observational studies, case reports, and guidelines on the diagnosis and treatment of cardioembolic stroke.

LATEST DEVELOPMENTS

Several pathologies can lead to cardioembolic stroke, including atrial fibrillation, aortic arch atheroma, patent foramen ovale, left ventricular dysfunction, and many others. Secondary stroke prevention strategies differ across these heterogeneous mechanisms. In addition to medical treatment advances such as the use of direct oral anticoagulants in patients with atrial fibrillation, surgical treatments such as closure of patent foramen ovale have been shown to reduce the risk of recurrent stroke in select patients. Furthermore, left atrial appendage occlusion is a promising strategy for patients with atrial fibrillation who are candidates for short-term oral anticoagulation therapy but not long-term oral anticoagulation therapy.

ESSENTIAL POINTS

A thorough diagnostic evaluation is essential to determine cardioembolic causes of stroke. In addition to risk factor management and lifestyle modifications, identification and targeting of the underlying cardioembolic stroke mechanisms will lead to improved stroke prevention strategies in patients with cardioembolic stroke.

Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies

The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.