After reviewing the latest evidence on the subject, an international panel of experts has this week made a number of recommendations for the management of patients aged less than 60 years with cryptogenic stroke and patent foramen ovale (PFO). Using the GRADE approach, they compared three options; PFO closure and antiplatelets to antiplatelets alone; PFO closure compared to anticoagulants; and anticoagulants compared to antiplatelets.
In the new BMJ Rapid Recommendation, they make a strong recommendation for PFO closure plus antiplatelet therapy compared with antiplatelet therapy alone. They make a weak recommendation for PFO closure plus antiplatelet therapy rather than anticoagulant therapy. For patients in whom closure is contraindicated or declined, they make a weak recommendation for anticoagulant therapy rather than antiplatelet therapy.
The authors note that 3.6 per cent of patients with PFO closure will experience an adverse event, but said such events do not usually result in long-term disability. The major downside of anticoagulation, they said, is the probable 2 per cent increase in bleeding risk over five years.
The panel concluded that further trials are needed to address remaining uncertainties, and that new evidence must be assessed to judge to what extent it may alter the recommendation.