AAN PFO Guidelines Bundle

© 2020 American Academy of Neurolog y Institute Figure 1. Management Algorithm a Vitamin K antagonist, a direct thrombin inhibitor, or a factor Xa inhibitor. Cryptogenic Stroke and PFO Hypercoagulable studies Brain imaging PFO Expertise Stroke Expertise Patient Counseling MRA or CTA TTE/TEE Patient opts for medical therapy <60 yrs, with PFO and embolic-appearing infarct and no other mechanism of stroke identified (after discussion of potential benefits and risks) OR 60–65 yrs with embolic-appearing infarct, very limited traditional vascular risk factors and no other mechanism of stroke detected OR Younger (<30 years) with single, small, deep stroke, a large shunt and no vascular risk factors Patients who would otherwise be considered good candidates for PFO closure but require long-term anticoagulation because of suspected or proved hypercoagulability May recommend PFO closure followed by lifelong antiplatelet therapy Aspirin or anticoagulation a Patient counseling that the efficacy of PFO closure in addition to anticoagulation cannot be confirmed or refuted Suspect AF? >28-day rhythm monitoring 106 Commerce Street, Suite 105 Lake Mary, FL 32746 TEL: 407.878.7606 • FAX: 407.878.7611 Order additional copies at GuidelineCentral.com Disclaimer Practice advisories published by the American Academy of Neurolog y are assessments of current scientific and clinical information provided as an educational service. e information (1) should not be considered inclusive of all proper treatments or as a statement of the standard of care; (2) is not continually updated and may not reflect the most recent evidence; (3) addresses only the question(s) specifically identified; (4) does not mandate any particular course of medical care; and (5) is not intended to substitute for the independent professional judgment of the treating provider. Use of the information is voluntary. e information is provided "as is" without warranty. AAN assumes no responsibility for any injury to persons arising out of or related to any use of this information or for any errors or omissions. e content of this tool was developed solely by the AAN and adapted by IGC, independent of external influence. Neither IGC, AAN, nor the authors endorse any product or service associated with the distributor of this tool. Abbreviations AF, atrial fibrillation; CTA; computed tomographic angiography; HR; hazard ratio; MRA; magnetic resonance angiography; PFO; patent foramen ovale; RR; risk ratio; TCD; transcranial Doppler ultrasonography; TEE; transesophageal echocardiography; TTE; transthoracic echocardiography Source Steven R. Messé, MD; Gary S. Gronseth, MD; David M. Kent, MD, MSc; Jorge R. Kizer, MD, MSc; Shunichi Homma, MD; Lee Rosterman, DO; John D. Carroll, MD; Koto Ishida, MD; Navdeep Sangha, MD; Scott E. Kasner, MD, MSCE. Practice advisory update: Patent foramen ovale and secondary stroke prevention. Report of the Guideline Subcommittee of the American Academy of Neurolog y. Neurolog y 2020;94(20):876-885 is practice advisory was endorsed by the Society for Cardiovascular Angiography and Interventions, the American Heart Association/American Stroke Association, and the European Academy of Neurolog y. Patent Foramen Ovale Secondary Stroke Prevention Resources 1. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with strial fibrillation: a report of the American College of Cardiolog y/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2019;16:e66-e93. 2. Tektonidou MG, Andreoli L, Limper M, et al. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis 2019;78:1296-1304. ECG

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