AAN PFO Guidelines Bundle

© 2020 American Academy of Neurolog y Institute ➤ Before undergoing PFO closure, patients should be assessed by a clinician with expertise in stroke to ensure that the PFO is the most plausible mechanism of stroke (B). ➤ If a higher risk alternative mechanism of stroke is identified, clinicians should not routinely recommend PFO closure (B). ➤ Before undergoing PFO closure, patients should be assessed by a clinician with expertise in assessing the degree of shunting and anatomical features of a PFO and performing PFO closure, to assess whether the PFO is anatomically appropriate for closure, to ascertain whether other factors are present that could modify the risk of the procedure, and to address post-procedure management (B). ➤ In patients with a PFO detected after stroke and no other etiology identified after a thorough evaluation, 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 (B). ➤ In patients younger than 60 years with a PFO and an embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (reduction of stroke recurrence) and risks (procedural complication and atrial fibrillation) (C). ➤ Clinicians may inform patients that presence of a large shunt probably is associated with benefit from closure. Conversely, there probably is less likelihood of benefit in patients with a small shunt or a non–embolic-appearing single, small, deep infarct, and it is uncertain whether atrial septal aneurysm in the absence of a large shunt influences the likelihood of benefitting from PFO closure (C). ➤ PFO closure may be offered in other populations, such as for a patient who is 60–65 years old with a very limited degree of traditional vascular risk factors (i.e., hypertension, diabetes, hyperlipidemia, or smoking) and no other mechanism of stroke detected following a thorough evaluation, including prolonged monitoring for atrial fibrillation (C). ➤ PFO closure may be offered to younger patients (e.g., <30 years) with a single, small, deep stroke (<1.5 cm), a large shunt, and absence of any vascular risk factors that would lead to intrinsic small-vessel disease such as hypertension, diabetes, or hyperlipidemia (C). ➤ In a patient for whom PFO closure is being considered, a shared decision-making approach between clinicians and the patient should be used, exploring how well the patient's attributes match those included in the positive PFO closure trials and the patient's preferences and concerns regarding risk of stroke recurrence and risk of adverse events (B). Recommendations Regarding Medical Therapy ➤ In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend either an antiplatelet medication such as aspirin or anticoagulation (using a vitamin K antagonist, a direct thrombin inhibitor, or a factor Xa inhibitor) (C). ➤ In patients who would otherwise be considered good candidates for PFO closure but require long-term anticoagulation because of suspected or proven hypercoagulability (defined thrombophilia, unprovoked deep venous thrombosis, or unprovoked pulmonary embolism), clinicians should counsel the patient that the efficacy of PFO closure in addition to anticoagulation cannot be confirmed or refuted (B). Classification of Management Recommendations Classification Definition Level (A) Denotes a practice recommendation that must be done. In almost all circumstances, adherence to the recommendation will improve health-related outcomes. Almost all patients in this circumstance would desire that the recommendation be followed. Level (B) Corresponds to the helping verb should. Should recommendations tend to be more common, as the requirements are less stringent but still based on the evidence and benefit-risk profile. Level (C) Corresponds to the helping verb may. May recommendations represent the lowest allowable recommendation level the AAN considers useful within the scope of clinical practice and can accommodate the highest degree of practice variation. Level (U) Indicates that the available evidence is insufficient to support or refute the efficacy of an intervention. Level (R) Assigned when the balance of benefits and harms is unknown and the intervention is known to be exorbitantly expensive or have important risks. is level designates that the intervention should not be used outside of a research setting. Patent Foramen Ovale Secondary Stroke Prevention Management (cont'd)

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