AAN Publishes Practice Advisory on PFO and Secondary Stroke Prevention

April 29, 2020—The American Academy of Neurology (AAN) published a practice advisory update summary on patent foramen ovale (PFO) and secondary stroke prevention. The report by Steven R. Messé, MD, et al is available online in Neurology. 

Updating the 2016 practice advisory, the AAN guideline panel followed the AAN 2017 guideline development process to systematically review studies published through December 2017 and formulate recommendations.

As listed in Neurology, the following are the major recommendations:

• In patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke (level B).
• In patients with a higher risk of alternative mechanism of stroke identified, clinicians should not routinely recommend PFO closure (level B).
• Clinicians should counsel patients that having a PFO is common; that it occurs in about 1 in 4 adults in the general population; that it is difficult to determine with certainty whether their PFO caused their stroke; and that PFO closure probably reduces recurrent stroke risk in select patients (level B).
• In patients < 60 years of age with a PFO and embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (absolute recurrent stroke risk reduction of 3.4% at 5 years) and risks (periprocedural complication rate of 3.9% and the increased absolute rate of nonperiprocedural atrial fibrillation of 0.33% per year) (level C).
• In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend an antiplatelet medication such as aspirin or anticoagulation (level C).