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Shijoh Y, Saito S, Dai Z, Ohde S. Cost-effectiveness analysis of patent foramen ovale closure versus medical therapy alone after cryptogenic stroke. PLoS One 2022; 17:e0268690. [PMID: 35657973 PMCID: PMC9165785 DOI: 10.1371/journal.pone.0268690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/04/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Closure of a patent foramen ovale reduces the risk of recurrent stroke compared with medical therapy alone in young patients with cryptogenic strokes revealed by randomized control trials. Some cost-effectiveness analyses outside Japan have shown that patent foramen ovale closure is cost-effective, but no studies have examined cost-effectiveness in Japan. The objective of this study is to assess cost-effectiveness, from the perspective of a Japanese healthcare payer, of patent foramen ovale closure versus medical therapy alone for patients with patent foramen ovale related to cryptogenic strokes.
Methods
A cost-effectiveness study was conducted by developing a decision tree and a Markov model. Probabilities and a 5.9-year time horizon followed the RESPECT study. Utilities and costs were based upon published studies and assumptions. All assumptions were assessed by experts, including a cardiologist and a statistical expert. The target population comprised patients with cryptogenic stroke and patent foramen ovale, aged 60 years or younger. The model was discounted at 2.0% and its cycle was one month. A willingness-to-pay threshold is set at $50,000 / quality-adjusted life years (QALYs). Incremental cost-effectiveness ratio was evaluated. Then one-way sensitivity analyses as deterministic sensitivity analysis, and probabilistic sensitivity analyses were performed to assess data robustness.
Results
Incremental quality-adjusted life years, incremental costs, and incremental cost-effectiveness ratio were 0.464, $13,562, and $29,208 per QALY gained, respectively. One-way sensitivity analysis showed that the stable state utility score difference between patent foramen ovale closure and medical therapy had the largest impact on incremental cost-effectiveness ratio. Patent foramen ovale closure is cost-effective at a stable state utility score difference of >0.051, compared with medical therapy. Probabilistic sensitivity analyses demonstrated that patent foramen ovale closure was 50.3% cost-effective.
Conclusions
Patent foramen ovale closure was cost-effective compared with medical therapy for Japanese patients with cryptogenic stroke who were ≤60 years.
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Affiliation(s)
- Yoko Shijoh
- Graduate School of Public Health St. Luke’s International University, Chuo-City, Tokyo, Japan
- * E-mail:
| | - Shota Saito
- Niigata University Graduate School of Medical and Dental Sciences, Niigata-City, Niigata, Japan
| | - Zhehao Dai
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Bunkyo-City, Tokyo, Japan
- Department of Cardiovascular Medicine, St. Luke’s International Hospital, Chuo-City, Tokyo, Japan
| | - Sachiko Ohde
- Graduate School of Public Health St. Luke’s International University, Chuo-City, Tokyo, Japan
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2
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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3278] [Impact Index Per Article: 655.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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Arfaras-Melainis A, Palaiodimos L, Mojadidi MK. Transcatheter Closure of Patent Foramen Ovale: Randomized Trial Update. Interv Cardiol Clin 2019; 8:341-356. [PMID: 31445719 DOI: 10.1016/j.iccl.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A patent foramen ovale (PFO) is found in about one-quarter of all adults, but the prevalence increases to approximately half of those with a history of a so-called cryptogenic stroke. The true efficacy of PFO closure for prevention of recurrent paradoxical embolism has been debated for years, as the early 3 randomized trials did not show a statistically significant benefit of PFO closure over standard-of-care medical therapy. However, 3 recent randomized trials along with the long-term follow-up data from the largest early trial demonstrated superiority of device closure for secondary stroke prevention.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Second Cardiology Department, National and Kapodistrian University of Athens, Attikon University Hospital, 1 Rimini Street, Haidari, Athens 12462, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Division of Hospital Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Mohammad K Mojadidi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, 1101 East Marshall Street, Richmond, VA 23298, USA
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4
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Topcuoglu MA, Arsava EM. The Fragility Index in Randomized Controlled Trials for Patent Foramen Ovale Closure in Cryptogenic Stroke. J Stroke Cerebrovasc Dis 2019; 28:1636-1639. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/12/2019] [Accepted: 02/23/2019] [Indexed: 01/10/2023] Open
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5
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Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol 2019; 17:790-801. [PMID: 30129475 DOI: 10.1016/s1474-4422(18)30233-3] [Citation(s) in RCA: 205] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/01/2018] [Accepted: 06/05/2018] [Indexed: 01/15/2023]
Abstract
Epidemiological evidence suggests that the incidence of ischaemic stroke in young adults (18-50 years) has increased substantially. These patients have a long life expectancy after stroke, and the costs of long-term care pose huge challenges to health-care systems. Although the current recommendations for treatment of young and old (>50 years) patients with stroke are similar, the optimal management of young adult patients with stroke is unknown. They are usually not included in trials, and specific subanalyses limited to young adult patients with stroke are usually not done, owing to lower incidence of stroke and lower prevalence of vascular risk factors in young adults. Progress has been made in identifying patients with a considerable risk of stroke occurrence, such as those with patent foramen ovale. Future prevention studies might result in a decrease in the incidence of stroke and its sequelae in young adults. The development of guidelines specifically devoted to the management of stroke in young adults will be an important step in achieving this aim.
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6
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Madhkour R, Meier B. Ictus criptogénico con un foramen oval permeable: ¿cuándo se debe cerrar? Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2018.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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7
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Sá MPBO, Vieira EES, Cavalcanti LRP, Diniz RGS, Rayol SDC, Menezes AMD, Lins RFDA, Lima RC. Updated Meta-analysis on the Closure of Patent Foramen Ovale in Reduction of Stroke Rates: the DEFENSE-PFO Trial Does not Change the Scenario. Braz J Cardiovasc Surg 2019; 33:511-521. [PMID: 30517261 PMCID: PMC6257535 DOI: 10.21470/1678-9741-2018-0194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/16/2018] [Indexed: 01/24/2023] Open
Abstract
Objective We aimed to analyze whether patent foramen ovale (PFO) closure reduces the
risk of stroke, assessing also some safety outcomes after the publication of
a new trial. Introduction The clinical benefit of closing a PFO has been an open question, so it is
necessary to review the current state of published medical data in regards
to this subject. Methods MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference
lists of relevant articles were used to search for randomized controlled
trials (RCTs) that reported any of the following outcomes: stroke, death,
major bleeding or atrial fibrillation. Six studies fulfilled our eligibility
criteria and included 3560 patients (1889 for PFO closure and 1671 for
medical therapy. Results The risk ration (RR) for stroke in the “closure” group compared with the
“medical therapy” showed a statistically significant difference between the
groups, favouring the “closure” group (RR 0.366; 95%CI 0.171–0.782,
P=0.010). There was no statistically significant
difference between the groups regarding the safety outcomes, death and major
bleeding, but we observed an increase in the risk of atrial fibrillation in
the “closure” group (RR 4.131; 95%CI 2.293–7.443,
P<0.001). We also observed that the larger the
proportion of effective closure, the lower the risk of stroke. Conclusion This meta-analysis found that stroke rates are lower with percutaneously
implanted device closure than with medical therapy alone, being these rates
modulated by the rates of hypertension, atrial septal aneurysm and effective
closure. The publication of a new trial did not change the scenario in the
medical literature.
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Affiliation(s)
- Michel Pompeu Barros Oliveira Sá
- Department of Cardiovascular Surgery of the Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE, Brazil.,Universidade de Pernambuco (UPE), Recife, PE, Brazil.,Nucleus of Postgraduate Studies and Research in Health Sciences of the Faculdade de Ciências Médicas and Instituto de Ciências Biológicas (FCM/ICB), Recife, PE, Brazil.,The CASUAL Investigators - CArdiovascular SUgery Academic League of the Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Erik Everton Silva Vieira
- Department of Cardiovascular Surgery of the Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE, Brazil.,Universidade de Pernambuco (UPE), Recife, PE, Brazil.,The CASUAL Investigators - CArdiovascular SUgery Academic League of the Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Luiz Rafael Pereira Cavalcanti
- Department of Cardiovascular Surgery of the Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE, Brazil.,Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Roberto Gouveia Silva Diniz
- Department of Cardiovascular Surgery of the Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE, Brazil.,Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Sérgio da Costa Rayol
- Department of Cardiovascular Surgery of the Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE, Brazil.,Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Alexandre Motta de Menezes
- Department of Cardiovascular Surgery of the Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE, Brazil.,Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Ricardo Felipe de Albuquerque Lins
- Department of Cardiovascular Surgery of the Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE, Brazil.,Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Ricardo Carvalho Lima
- Department of Cardiovascular Surgery of the Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE, Brazil.,Universidade de Pernambuco (UPE), Recife, PE, Brazil.,Nucleus of Postgraduate Studies and Research in Health Sciences of the Faculdade de Ciências Médicas and Instituto de Ciências Biológicas (FCM/ICB), Recife, PE, Brazil.,The CASUAL Investigators - CArdiovascular SUgery Academic League of the Universidade de Pernambuco (UPE), Recife, PE, Brazil
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8
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Schulz UG. Cryptogenic stroke - How to make sense of a non-diagnostic entity. Maturitas 2019; 122:44-50. [PMID: 30797529 DOI: 10.1016/j.maturitas.2019.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/10/2019] [Indexed: 01/26/2023]
Abstract
Secondary preventive strategies in ischaemic stroke depend on the underlying aetiology. However, approximately one-third of ischaemic strokes remain unexplained, or 'cryptogenic'. There is a wide range of possible underlying causes in cryptogenic stroke, and the best approach to secondary prevention of these may differ. To date, though, the widely accepted and uniform secondary preventive strategy in this group consists of modification of vascular risk factors, and of treatment with a combination of antiplatelet therapy and antihypertensive and lipid-lowering medication. Among the potential causes for cryptogenic stroke are occult atrial fibrillation, patent foramen ovale, atrial cardiopathy, aortic arch atheroma and hypercoagulable states. While it is possible to diagnose these conditions, in individual patients there is often uncertainty over whether they have a directly causative role, are markers of disease, or are innocent bystanders. Similarly, even if the cause is found, the best secondary preventive strategies remain uncertain, which questions the benefit of extensive investigations in a clinical setting. More recently, the concept of "embolic stroke of unknown source (ESUS)" has been introduced, in the hope that anticoagulation may offer better secondary prevention than antiplatelet therapy, but trials so far have been negative. At present, there is little justification for introducing extensive new investigative strategies into the management of patients with cryptogenic stroke. Investigations should be targeted at identifying those high-risk conditions which lead to a change in management. Further investigations need to be tailored individually, according to clinical circumstances. This should include identifying patients for participation in clinical trials, as the significance and best management of many of the potential causes for cryptogenic stroke require further research.
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Affiliation(s)
- Ursula G Schulz
- Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK.
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9
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Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EUROINTERVENTION 2019; 14:1389-1402. [PMID: 30141306 DOI: 10.4244/eij-d-18-00622] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
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10
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Palaiodimos L, Kokkinidis D. Questions on Percutaneous Patent Foramen Ovale Closure for Secondary Stroke Prevention: The Heads of the Lernaean Hydra. Cardiology 2019; 144:50-52. [DOI: 10.1159/000501231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 11/19/2022]
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11
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Madhkour R, Meier B. PFO and Cryptogenic Stroke: When Should It Be Closed? ACTA ACUST UNITED AC 2018; 72:369-372. [PMID: 30553802 DOI: 10.1016/j.rec.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/12/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Raouf Madhkour
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Bernhard Meier
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland.
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12
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Fiorelli EM, Carandini T, Gagliardi D, Bozzano V, Bonzi M, Tobaldini E, Comi GP, Scarpini EA, Montano N, Solbiati M. Secondary prevention of cryptogenic stroke in patients with patent foramen ovale: a systematic review and meta-analysis. Intern Emerg Med 2018; 13:1287-1303. [PMID: 30032341 DOI: 10.1007/s11739-018-1909-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/12/2018] [Indexed: 01/27/2023]
Abstract
The aim of our study is to compare patent foramen ovale (PFO) closure versus medical treatment and antiplatelet versus anticoagulant therapy in patients with cryptogenic stroke (CS) and PFO. We conducted a systematic review and meta-analysis with trial sequential analysis (TSA) of randomized trials. Primary outcomes are stroke or transient ischemic attack (TIA) and all-cause mortality. Secondary outcomes are peripheral embolism, bleeding, serious adverse events, myocardial infarction and atrial dysrhythmias. We performed an intention to treat meta-analysis with a random-effects model. We include six trials (3677 patients, mean age 47.3 years, 55.8% men). PFO closure is associated with a lower recurrence of stroke or TIA at a mean follow-up of 3.88 years compared to medical therapy [risk ratio (RR) 0.55, 95% CI 0.38-0.81; I2 = 40%]. The TSA confirms this result. No difference is found in mortality (RR 0.74, 95% CI 0.35-1.60; I2 = 0%), while PFO closure is associated with a higher incidence of atrial dysrhythmias (RR 4.55, 95% CI 2.16-9.60; I2 = 25%). The rate of the other outcomes is not different among the two groups. The comparison between anticoagulant and antiplatelet therapy shows no difference in terms of stroke recurrence, mortality and bleeding. There is conclusive evidence that PFO closure reduces the recurrence of stroke or TIA in patients younger than 60 years of age with CS. More data are warranted to assess the consequences of the increase in atrial dysrhythmias and the advantage of PFO closure over anticoagulants.
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Affiliation(s)
- Elisa Maria Fiorelli
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Tiziana Carandini
- Neurodegenerative Disease Unit, University of Milan, Dino Ferrari Centre, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Delia Gagliardi
- Dino Ferrari Centre, Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Neurology Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Viviana Bozzano
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Mattia Bonzi
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Eleonora Tobaldini
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giacomo Pietro Comi
- Dino Ferrari Centre, Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Neurology Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Elio Angelo Scarpini
- Neurodegenerative Disease Unit, University of Milan, Dino Ferrari Centre, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Monica Solbiati
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Ahmad Y, Howard J, Arnold A, Shun-Shin M, Cook C, Francis D, Sen S. Reply to: Assessing the quality of evidence supporting patent foramen ovale closure over medical therapy after cryptogenic stroke. Eur Heart J 2018; 39:3620. [PMID: 30137277 DOI: 10.1093/eurheartj/ehy498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
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14
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Lai JCL, Tse G, Wu WK, Gong M, Bazoukis G, Wong WT, Wong SH, Lampropoulos K, Baranchuk A, Tse LA, Xia Y, Li G, Wong MC, Chan YS, Mu N, Dong M, Liu T. Patent foramen ovale closure versus medical therapy for stroke prevention: A systematic review and meta-analysis of randomized controlled trials. F1000Res 2018; 6:2178. [PMID: 30271571 PMCID: PMC6137413 DOI: 10.12688/f1000research.13444.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Previous randomized trials on patent foramen ovale (PFO) closure versus medical therapy for stroke prevention were inconclusive. Recently, two new randomized trials and new findings from an extended follow-up of a previous trial have been published on this topic. We conducted a systematic review and meta-analysis of randomized trials comparing PFO closure with medical therapy for stroke prevention. Methods: PubMed and Cochrane Library were searched until 16
th September 2017. The following search terms were used for PubMed: "patent foramen ovale" AND (stroke OR embolism) and "randomized" AND "Trial". For Cochrane Library, the following terms were used: "patent foramen ovale" AND "closure" AND (stroke OR embolism). Results: A total of 91 and 55 entries were retrieved from each database using our search strategy respectively, of which six studies on five trials met the inclusion criteria. This meta-analysis included 1829 patients in the PFO closure arm (mean age: 45.3 years; 54% male) and 1972 patients in the medical therapy arm (mean age: 45.1 years; 51% male). The median follow-up duration was 50 ± 30 months. When compared to medical therapy, PFO closure significantly reduced primary endpoint events with a risk ratio [RR] of 0.60 (95% CI: 0.44-0.83, P < 0.0001;
I2: 15%). It also reduced stroke (RR: 0.50, 95% CI: 0.35-0.73, P < 0.0001;
I2: 32%) despite increasing the risk of atrial fibrillation/flutter (RR: 1.90, 95% CI: 1.23-2.93, P < 0.01;
I2: 43%). However, it did not reduce transient ischemic accident events (0.75; 95% CI: 0.51-1.10, P = 0.14;
I2: 0%), all-cause bleeding (RR: 0.89; 95% CI: 0.44-1.78, P = 0.74;
I2: 51%) or gastrointestinal complications (RR: 0.92; 95% CI: 0.32-2.70, P = 0.88;
I2: 0%). Conclusions: PFO closure significantly reduces risk of stroke when compared to medical treatment and should therefore be considered for stroke prevention in PFO patients.
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Affiliation(s)
- Jenny Chi Ling Lai
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K.K. Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - George Bazoukis
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Agrobiotechnology, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny Hei Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
| | - Lap Ah Tse
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yunlong Xia
- Department of Cardiovascular Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Martin C.S. Wong
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yat Sun Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Nan Mu
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Mei Dong
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
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15
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Cryptogenic Stroke and Patent Foramen Ovale. J Am Coll Cardiol 2018; 72:1183-1185. [DOI: 10.1016/j.jacc.2018.03.549] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 03/22/2018] [Accepted: 03/29/2018] [Indexed: 01/16/2023]
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Mojadidi MK, Elgendy AY, Elgendy IY, Mahmoud AN, Meier B. Atrial Fibrillation After Percutaneous Patent Foramen Ovale Closure. Am J Cardiol 2018; 122:915. [PMID: 30064865 DOI: 10.1016/j.amjcard.2018.05.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 05/21/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Mohammad K Mojadidi
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine; Gainesville, Florida.
| | - Akram Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine; Gainesville, Florida
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine; Gainesville, Florida
| | - Ahmed N Mahmoud
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine; Gainesville, Florida
| | - Bernhard Meier
- Department of Cardiology, University Hospital of Bern; Bern, Switzerland
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Net clinical benefit of patent foramen ovale closure in patients with cryptogenic stroke: Meta-analysis and meta-regression of randomized trials. Int J Cardiol 2018; 266:75-80. [DOI: 10.1016/j.ijcard.2018.02.106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 02/22/2018] [Accepted: 02/26/2018] [Indexed: 02/07/2023]
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18
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Messerli FH, Meier B. Patent Foramen Ovale Closure-When Number Needed to Treat and Number Needed to Harm Do Not Tell the Whole Story. Am J Cardiol 2018. [PMID: 29526274 DOI: 10.1016/j.amjcard.2018.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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19
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Topcuoglu MA, Liu L, Kim DE, Gurol ME. Updates on Prevention of Cardioembolic Strokes. J Stroke 2018; 20:180-196. [PMID: 29886716 PMCID: PMC6007290 DOI: 10.5853/jos.2018.00780] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/16/2018] [Accepted: 05/23/2018] [Indexed: 01/01/2023] Open
Abstract
Cardiac embolism continues to be a leading etiology of ischemic strokes worldwide. Although pathologies that result in cardioembolism have not changed over the past decade, there have been significant advances in the treatment and stroke prevention methods for these conditions. Atrial fibrillation remains the prototypical cause of cardioembolic strokes. The availability of new long-term monitoring devices for atrial fibrillation detection such as insertable cardiac monitors has allowed accurate detection of this leading cause of cardioembolism. The non-vitamin K antagonist oral anticoagulants have improved our ability to prevent strokes for many patients with non-valvular atrial fibrillation (NVAF). Advances in left atrial appendage closure and the U.S. Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device for stroke prevention in NVAF patients who have an appropriate rationale for a nonpharmacological alternative, have revolutionized the field and provided a viable option for patients at higher hemorrhagic risk. The role of patent foramen ovale closure for secondary prevention in selected patients experiencing cryptogenic ischemic strokes at a relatively young age has become clearer thanks to the very recent publication of long-term outcomes from three major studies. Advances in the management of infective endocarditis, heart failure, valvular diseases, and coronary artery disease have significantly changed the management of such patients, but have also revealed new concerns related to assessment of ischemic versus hemorrhagic risk in the setting of antithrombotic use. The current review article aims to discuss these advances especially as they pertain to the stroke neurology practice.
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Affiliation(s)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - M. Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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20
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Alushi B, Lauten A, Cassese S, Colleran R, Schüpke S, Rai H, Schunkert H, Meier B, Landmesser U, Kastrati A. Patent foramen ovale closure versus medical therapy for prevention of recurrent cryptogenic embolism: updated meta-analysis of randomized clinical trials. Clin Res Cardiol 2018; 107:788-798. [PMID: 29644412 DOI: 10.1007/s00392-018-1246-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/09/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND We performed an updated meta-analysis of all randomized-controlled trials (RCTs) comparing patent foramen ovale (PFO) closure with medical therapy for prevention of recurrent ischemic stroke. METHODS AND RESULTS We searched Medline, EMBASE, and Cochrane databases, and proceedings of international meetings for RCTs of patients with cryptogenic stroke and PFO comparing percutaneous PFO closure versus medical therapy for prevention of recurrent ischemic stroke. The primary outcome was a composite ischemic/embolic endpoint comprising stroke, transient ischemic attack (TIA), peripheral embolism, and early death in the intention-to-treat population. Secondary outcomes were all-cause death, stroke, TIA, atrial fibrillation (AF), and major bleeding. Of 3440 enrolled patients across five RCTs, 1829 were allocated to PFO closure and 1611 to medical therapy. The follow-up ranged from 2 to 5.9 years. PFO closure reduced the risk of the composite outcome [HR 0.52, (0.36-0.77); p < 0.01], and stroke, [HR 0.39, (0.19-0.83); p < 0.01], and increased the risk of AF [OR 3.75, (2.44-5.78); p < 0.01] as compared to medical therapy. NNT for stroke was 37 and NNH for AF 49, indicating a net clinical benefit of PFO closure. The meta-analysis had 95% power to detect a 50% relative risk reduction (RRR) in the primary outcome and 89% power to detect a 70% RRR in ischemic stroke. The risk of all-cause death (HR 1.08, p = 0.90), TIA [HR 0.73, (0.49-1.09); p = 0.12], and major bleeding [OR 0.97, (0.44-2.17); p = 0.95] was comparable between the groups. CONCLUSIONS Among patients with cryptogenic stroke and PFO, percutaneous closure of PFO is superior to medical therapy in preventing recurrent ischemic/embolic events and stroke but is associated with an increased risk of AF.
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Affiliation(s)
- Brunilda Alushi
- Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charite'-Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Alexander Lauten
- Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charite'-Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Salvatore Cassese
- German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Roisin Colleran
- German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Stefanie Schüpke
- German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Himanshu Rai
- German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Heribert Schunkert
- German Heart Center Munich, Technische Universität München, Munich, Germany.,DZHK, Partner Site Munich Heart Alliance, Munich, Germany
| | - Bernhard Meier
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Ulf Landmesser
- Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charite'-Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Adnan Kastrati
- German Heart Center Munich, Technische Universität München, Munich, Germany. .,DZHK, Partner Site Munich Heart Alliance, Munich, Germany. .,Department of Cardiology, German Heart Centre, Munich, Lazarettstraße 36, Munich, Germany.
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21
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Palaiodimos L, Kokkinidis DG, Faillace RT, Foley TR, Dangas GD, Price MJ, Mastoris I. Percutaneous closure of patent foramen ovale vs. medical treatment for patients with history of cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:852-858. [PMID: 29576519 DOI: 10.1016/j.carrev.2018.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/04/2018] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with history of cryptogenic stroke are more likely to have a patent foramen ovale (PFO) and should be managed with antithrombotic agents, while the alternative option is percutaneous closure of PFOs. Our aim was to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous closure vs. medical treatment for patients with PFO and prior cryptogenic stroke. METHODS Medline, Scopus and Cochrane databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. New ischemic stroke was defined as the primary endpoint. A sensitivity analysis was performed for Amplatzer device. Subgroup analyses were performed for different patient and PFO characteristics for the composite endpoints as defined by the included RCTs. RESULTS In total of 3440 patients were included in this meta-analysis. Closure devices were superior to medical therapy for prevention of recurrent ischemic strokes (HR = 0.29; CI: 0.02-0.56), but were associated with increased risk of new onset of atrial fibrillation (AF) and atrial flutter (RR = 4.67; CI: 2.22-9.81). However, in the sensitivity analysis for Amplatzer device, there was no difference between the two groups in new onset of atrial arrhythmias. Closure devices were superior across all different subgroups when compared to medical treatment with the exception of patients with a small shunt. CONCLUSION This meta-analysis shows that closure devices for patients with PFO and history of cryptogenic stroke can significantly decrease the risk of a new ischemic stroke. The use of Amplatzer device was not associated with increased risk of newly diagnosed atrial arrhythmias.
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Affiliation(s)
- Leonidas Palaiodimos
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States.
| | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Robert T Faillace
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - T Raymond Foley
- Cardiac Catheterization Laboratory, Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA, United States
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, NY, New York, United States
| | - Matthew J Price
- Cardiac Catheterization Laboratory, Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA, United States
| | - Ioannis Mastoris
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
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22
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Lai JCL, Tse G, Wu WK, Gong M, Bazoukis G, Wong WT, Wong SH, Lampropoulos K, Baranchuk A, Tse LA, Xia Y, Li G, Wong MC, Chan YS, Mu N, Dong M, Liu T. Patent foramen ovale closure versus medical therapy for stroke prevention: A systematic review and meta-analysis of randomized controlled trials. F1000Res 2017; 6:2178. [PMID: 30271571 PMCID: PMC6137413 DOI: 10.12688/f1000research.13444.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 10/11/2023] Open
Abstract
Background: Previous randomized trials on patent foramen ovale (PFO) closure versus medical therapy for stroke prevention were inconclusive. Recently, two new randomized trials and new findings from an extended follow-up of a previous trial have been published on this topic. We conducted a systematic review and meta-analysis of randomized trials comparing PFO closure with medical therapy for stroke prevention. Methods: PubMed and Cochrane Library were searched until 16 th September 2017. The following search terms were used for PubMed: "patent foramen ovale" AND (stroke OR embolism) and "randomized" AND "Trial". For Cochrane Library, the following terms were used: "patent foramen ovale" AND "closure" AND (stroke OR embolism). Results: A total of 91 and 55 entries were retrieved from each database using our search strategy respectively, of which six studies on five trials met the inclusion criteria. This meta-analysis included 1829 patients in the PFO closure arm (mean age: 45.3 years; 54% male) and 1972 patients in the medical therapy arm (mean age: 45.1 years; 51% male). The median follow-up duration was 50 ± 30 months. When compared to medical therapy, PFO closure significantly reduced primary endpoint events with a risk ratio [RR] of 0.60 (95% CI: 0.44-0.83, P < 0.0001; I 2: 15%). It also reduced stroke (RR: 0.50, 95% CI: 0.35-0.73, P < 0.0001; I 2: 32%) despite increasing the risk of atrial fibrillation/flutter (RR: 1.90, 95% CI: 1.23-2.93, P < 0.01; I 2: 43%). However, it did not reduce transient ischemic accident events (0.75; 95% CI: 0.51-1.10, P = 0.14; I 2: 0%), all-cause bleeding (RR: 0.89; 95% CI: 0.44-1.78, P = 0.74; I 2: 51%) or gastrointestinal complications (RR: 0.92; 95% CI: 0.32-2.70, P = 0.88; I 2: 0%). Conclusions: PFO closure significantly reduces risk of stroke when compared to medical treatment and should therefore be considered for stroke prevention in PFO patients.
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Affiliation(s)
- Jenny Chi Ling Lai
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K.K. Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - George Bazoukis
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Agrobiotechnology, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny Hei Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
| | - Lap Ah Tse
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yunlong Xia
- Department of Cardiovascular Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Martin C.S. Wong
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yat Sun Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Nan Mu
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Mei Dong
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - International Health Informatics Study (IHIS) Network
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Agrobiotechnology, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Division of Cardiology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Cardiovascular Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
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