Difference between revisions of "Patent foramen ovale medical therapy"

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==Medical Therapy==
 
==Medical Therapy==
*There is a lack of consensus on the medical therapy of choice for the prevention of recurrent cryptogenic stroke in patients with patent foramen ovale. The controversy is between antiplatelets and anticoagulants.
+
*There is a lack of consensus on the medical therapy of choice for the prevention of recurrent [[cryptogenic stroke]] in patients with patent foramen ovale. The controversy is between antiplatelets and [[anticoagulants]].
*The incidence of recurrent [[strokes]] in patients with index episode of [[Paradoxical embolism|cryptogenic stroke]] and treated with [[aspirin]] or [[warfarin]] has been found to be similar in the presence or absence of a patent foramen ovale<ref name="pmid12045168">{{cite journal| author=Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptographic Stroke Study (PICSS) Investigators| title=Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. | journal=Circulation | year= 2002 | volume= 105 | issue= 22 | pages= 2625-31 | pmid=12045168 | doi= | pmc= | url= }} </ref>.
+
*The [[Incidence (epidemiology)|incidence]] of recurrent [[strokes]] in patients with index episode of [[Paradoxical embolism|cryptogenic stroke]] and treated with [[aspirin]] or [[warfarin]] has been found to be similar in the presence or absence of a patent foramen ovale<ref name="pmid12045168">{{cite journal| author=Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptographic Stroke Study (PICSS) Investigators| title=Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. | journal=Circulation | year= 2002 | volume= 105 | issue= 22 | pages= 2625-31 | pmid=12045168 | doi= | pmc= | url= }} </ref>.
*Warfarin is associated with greater hemorrhagic risk and requires more complex monitoring and therapeutic adjustments.  
+
*[[Warfarin]] is associated with greater [[hemorrhagic]] risk and requires more complex monitoring and therapeutic adjustments.
  
 
===Supportive Trial Data===
 
===Supportive Trial Data===
A large randomized multicenter trial (42 centers) was done to compare the relative efficacy of [[aspirin]] and [[warfarin]] to prevent recurrent [[stroke]]s in patients with patent foramen ovale<ref name="pmid12045168">{{cite journal| author=Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptogenic Stroke Study (PICSS) Investigators| title=Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. |journal=Circulation | year= 2002 | volume= 105 | issue= 22 | pages= 2625-31 | pmid=12045168 | doi= | pmc= | url= }} </ref>. The study found an increased incidence of patent foramen ovale with [[Paradoxical embolism | cryptogenic stroke]]. This was similar to the results found in previous small scale trials <ref name="pmid3362165">{{cite journal| author=Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M et al.| title=Prevalence of patent foramen ovale in patients with stroke. | journal=N Engl J Med | year= 1988 | volume= 318 | issue= 18 | pages= 1148-52 | pmid=3362165 | doi=10.1056/NEJM198805053181802 | pmc= |url= }} </ref><ref name="pmid2898621">{{cite journal| author=Webster MW, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM et al.| title=Patent foramen ovale in young stroke patients. | journal=Lancet | year= 1988 | volume= 2 | issue= 8601 | pages= 11-2 | pmid=2898621 | doi= | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2898621  }} </ref><ref name="pmid1503349">{{cite journal| author=Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S| title=Patent foramen ovale as a risk factor for cryptogenic stroke. |journal=Ann Intern Med | year= 1992 | volume= 117 | issue= 6 | pages= 461-5 | pmid=1503349 | doi= | pmc= | url= }} </ref>. Also, it was found in the study that[[Paradoxical embolism | cryptogenic stroke]]s were commoner in larger patent foramen ovale compared to the smaller. Nevertheless, the rate of recurrent [[stroke]] or [[death]], in medically treated patients after index episode of [[Paradoxical embolism | cryptogenic stroke]], was found to be similar between patients with and without patent foramen ovale. Also, the rate of adverse events after medical therapy was found to be the same in patent foramen ovale of different size.
+
A large randomized multicenter trial (42 centers) was done to compare the relative efficacy of [[aspirin]] and [[warfarin]] to prevent recurrent [[stroke]]s in patients with patent foramen ovale. The study found an increased [[Incidence (epidemiology)|incidence]] of patent foramen ovale with [[Paradoxical embolism | cryptogenic stroke]]. This was similar to the results found in previous small scale trials. Also, it was found in the study that[[Paradoxical embolism | cryptogenic stroke]]s were more common in larger patent foramen ovale compared to the smaller. Nevertheless, the rate of recurrent [[stroke]] or [[death]], in medically treated patients after index episode of [[Paradoxical embolism | cryptogenic stroke]], was found to be similar between patients with and without patent foramen ovale. Also, the rate of [[Adverse event|adverse events]] after medical therapy was found to be the same in patent foramen ovale of different size.<ref name="pmid12045168">{{cite journal| author=Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptogenic Stroke Study (PICSS) Investigators| title=Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. |journal=Circulation | year= 2002 | volume= 105 | issue= 22 | pages= 2625-31 | pmid=12045168 | doi= | pmc= | url= }} </ref><ref name="pmid3362165">{{cite journal| author=Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M et al.| title=Prevalence of patent foramen ovale in patients with stroke. | journal=N Engl J Med | year= 1988 | volume= 318 | issue= 18 | pages= 1148-52 | pmid=3362165 | doi=10.1056/NEJM198805053181802 | pmc= |url= }} </ref><ref name="pmid2898621">{{cite journal| author=Webster MW, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM et al.| title=Patent foramen ovale in young stroke patients. | journal=Lancet | year= 1988 | volume= 2 | issue= 8601 | pages= 11-2 | pmid=2898621 | doi= | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2898621  }} </ref><ref name="pmid1503349">{{cite journal| author=Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S| title=Patent foramen ovale as a risk factor for cryptogenic stroke. |journal=Ann Intern Med | year= 1992 | volume= 117 | issue= 6 | pages= 461-5 | pmid=1503349 | doi= | pmc= | url= }} </ref>.
  
 
===International Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale===
 
===International Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale===

Revision as of 21:19, 14 February 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [3]

Overview

The medical therapy for the patients with patent foramen ovale is controversial. Medical therapy with antiplatelet therapy (aspirin) or anticoagulant therapy (warfarin) could be considered in patients with recurrent strokes after index episode of cryptogenic stroke and unresponsive migraines. However, the relative effectiveness of aspirin or warfarin in these patients has not been proved.

Medical Therapy

  • There is a lack of consensus on the medical therapy of choice for the prevention of recurrent cryptogenic stroke in patients with patent foramen ovale. The controversy is between antiplatelets and anticoagulants.
  • The incidence of recurrent strokes in patients with index episode of cryptogenic stroke and treated with aspirin or warfarin has been found to be similar in the presence or absence of a patent foramen ovale[1].
  • Warfarin is associated with greater hemorrhagic risk and requires more complex monitoring and therapeutic adjustments.

Supportive Trial Data

A large randomized multicenter trial (42 centers) was done to compare the relative efficacy of aspirin and warfarin to prevent recurrent strokes in patients with patent foramen ovale. The study found an increased incidence of patent foramen ovale with cryptogenic stroke. This was similar to the results found in previous small scale trials. Also, it was found in the study that cryptogenic strokes were more common in larger patent foramen ovale compared to the smaller. Nevertheless, the rate of recurrent stroke or death, in medically treated patients after index episode of cryptogenic stroke, was found to be similar between patients with and without patent foramen ovale. Also, the rate of adverse events after medical therapy was found to be the same in patent foramen ovale of different size.[1][2][3][4].

International Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale

American Academy of Neurology Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[5][6]

Practice Recommendations

1) In the absence of another indication for anticoagulation, clinicians may routinely offer antiplatelet medications instead of anticoagulation to patients with cryptogenic stroke and PFO (Level C).

2) In rare circumstances, such as stroke that recurs while a patient is undergoing antiplatelet therapy, clinicians may offer anticoagulation to patients with cryptogenic stroke and PFO (Level C).

  • There is insufficient evidence to determine the efficacy of anticoagulants compared with antiplateles in preventing reccurent strokes in patients with crptogenic stroke and patent foramen ovale.
  • Among patients with a cryptogenic stroke and atrial septal abnormalities, there is insufficient evidence to determine the superiority of aspirin or warfarin for prevention of recurrent stroke or death (Level U), but the risks of minor bleeding are possibly greater with warfarin (Level C)

Rating of Recommendations

A = Established as effective, ineffective, or harmful for the given condition in the specified population.

B = Probably effective, ineffective, or harmful for the given condition in the specified population.

C = Possibly effective, ineffective, or harmful for the given condition in the specified population.

U = Data inadequate or conflicting. Given current knowledge, treatment (test, predictor) is unproven.

American Academy of Chest Physicians Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT) [7]

1) In patients with cryptogenic ischemic stroke and a PFO, we recommend antiplatelet therapy over no therapy (Grade 1A) and suggest antiplatelet therapy over warfarin (Grade 2A).

2) For patients with evidence of a DVT, anticoagulation therapy is recommended.

American Heart Association/American Stroke Association Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[8][9]

1) For patients with an ischaemic stroke or transient ischaemic attack and a PFO who are not undergoing anticoagulation therapy, antiplatelet therapy is recommended (Class I; Level of Evidence B).

2) For patients with an ischaemic stroke or transient ischaemic attack and both a PFO and a venous source of embolism, anticoagulation is indicated depending on stroke characteristics (Class I; Level of Evidence A). When anticoagulation is contraindicated, an inferior vena cava filter is reasonable (Class IIa; Level of Evidence C).

European Stroke Organisation Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[10]

1) Patients with cardioembolic stroke unrelated to atrial fibrillation should receive warfarin if the risk of recurrence is high.

References

  1. 1.0 1.1 Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptographic Stroke Study (PICSS) Investigators (2002). "Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study". Circulation. 105 (22): 2625–31. PMID 12045168.
  2. Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M; et al. (1988). "Prevalence of patent foramen ovale in patients with stroke". N Engl J Med. 318 (18): 1148–52. doi:10.1056/NEJM198805053181802. PMID 3362165.
  3. Webster MW, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM; et al. (1988). "Patent foramen ovale in young stroke patients". Lancet. 2 (8601): 11–2. PMID 2898621.
  4. Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S (1992). "Patent foramen ovale as a risk factor for cryptogenic stroke". Ann Intern Med. 117 (6): 461–5. PMID 1503349.
  5. Messé SR, Silverman IE, Kizer JR, Homma S, Zahn C, Gronseth G; et al. (2004). "Practice parameter: recurrent stroke with patent foramen ovale and atrial septal aneurysm: report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 62 (7): 1042–50. PMID 15078999.
  6. Messé, Steven R.; Gronseth, Gary; Kent, David M.; Kizer, Jorge R.; Homma, Shunichi; Rosterman, Lee; Kasner, Scott E. (2016). "Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter)". Neurology. 87 (8): 815–821. doi:10.1212/WNL.0000000000002961. ISSN 0028-3878.
  7. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P (2004). "Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy". Chest. 126 (3 Suppl): 483S–512S. doi:10.1378/chest.126.3_suppl.483S. PMID 15383482.
  8. Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC; et al. (2011). "Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association". Stroke. 42 (1): 227–76. doi:10.1161/STR.0b013e3181f7d043. PMID 20966421.
  9. Kernan, Walter N.; Ovbiagele, Bruce; Black, Henry R.; Bravata, Dawn M.; Chimowitz, Marc I.; Ezekowitz, Michael D.; Fang, Margaret C.; Fisher, Marc; Furie, Karen L.; Heck, Donald V.; Johnston, S. Claiborne (Clay); Kasner, Scott E.; Kittner, Steven J.; Mitchell, Pamela H.; Rich, Michael W.; Richardson, DeJuran; Schwamm, Lee H.; Wilson, John A. (2014). "Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack". Stroke. 45 (7): 2160–2236. doi:10.1161/STR.0000000000000024. ISSN 0039-2499.
  10. European Stroke Organisation (ESO) Executive Committee. ESO Writing Committee (2008). "Guidelines for management of ischaemic stroke and transient ischaemic attack 2008". Cerebrovasc Dis. 25 (5): 457–507. doi:10.1159/000131083. PMID 18477843.



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