Treatment of atrial septal abnormalities (PFO, ASD, and ASA) for prevention of stroke in adults
- Steven R Messé, MD
Steven R Messé, MD
- Associate Professor of Neurology
- Hospital of the University of Pennsylvania
- Naser M Ammash, MD
Naser M Ammash, MD
- Professor of Medicine
- Mayo Medical School
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- Heidi M Connolly, MD
Heidi M Connolly, MD
- Section Editor — Congenital Heart Disease
- Professor of Medicine
- Mayo Medical School
Therapeutic options for prevention of recurrent stroke in patients with an atrial septal abnormality, including patent foramen ovale (PFO), small ostium secundum atrial septal defect (ASD), and atrial septal aneurysm (ASA), are medical therapy with antiplatelet agents or anticoagulants, and surgical or percutaneous closure of the defect. Because of the uncertainty about the causal association between atrial septal abnormalities and stroke, the lack of gold standard treatment option and inconclusive data, some of the therapeutic options discussed below may prove to be overly aggressive. In addition to medical management, this topic will review the surgical and percutaneous options for the prevention of embolic stroke related to an atrial septal abnormality.
The true risk of primary or recurrent ischemic stroke associated with patent foramen ovale (PFO) and atrial septal aneurysm (ASA) continues to be difficult to estimate. However, available data can be summarized as follows (see "Atrial septal abnormalities (PFO, ASD, and ASA) and risk of cerebral emboli in adults", section on 'Conclusions'):
●A number of case-control studies have reported an increased prevalence of PFO in patients who have had a cryptogenic stroke, suggesting that PFO frequently facilitates the paradoxical embolism that causes cryptogenic stroke.
●In contrast, population-based cohort studies, which enrolled predominantly older subjects, have found no statistically significant association between the risk of first ischemic stroke and presence of a PFO.
●The RoPE score (table 1) estimates the probability that a PFO is incidental or pathogenic in a patient with cryptogenic stroke . The PFO-attributable fraction of stroke (table 2) varies widely and decreases with age and the presence of vascular risk factors. Differences in the PFO-attributable fraction of stroke probably explain the discrepant findings of the case-control and population-based studies. Subjects with cryptogenic stroke are generally younger and more likely to have a higher PFO-attributable fraction of stroke than the older subjects enrolled in the population-based studies.
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- STROKE RISK
- SECONDARY STROKE PREVENTION
- Antithrombotic therapy
- - Isolated PFO
- - PFO with ASA
- - Isolated ASA
- Closure of septal defect
- - Percutaneous closure of PFO
- - Percutaneous closure of PFO with ASA
- - Closure of ASD
- - Surgical closure of PFO
- Additional preventive measures
- Guideline recommendations
- PRIMARY STROKE PREVENTION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS