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
ECG
