Raffaele Ornello, MD

Sagris D, Georgiopoulos G, Perlepe K, Pateras K, Korompoki E, Makaritsis K, et al. Antithrombotic Treatment in Cryptogenic Stroke Patients With Patent Foramen Ovale: Systematic Review and Meta-Analysis. Stroke. 2019;50:3135–3140.

Patent foramen ovale (PFO) is a relevant potential cause of cryptogenic ischemic stroke, especially in young people. After a cryptogenic ischemic stroke in patients with PFO, it is unclear whether to start an antiplatelet or an anticoagulant agent.

In this article, the authors performed a systematic review and meta-analysis of randomized controlled trials to summarize the available evidence in the field and help orienting treatment. The authors found that anticoagulants were not superior to antiplatelets in the prevention of recurrent stroke in patients with cryptogenic stroke and PFO in the absence of different bleeding risk. However, the absolute effect sizes suggest a potentially larger preventive effect of anticoagulants over antiplatelets, warranting the feasibility of a large randomized controlled trial of non-vitamin K antagonist oral anticoagulants versus aspirin.

It should be noted that the trials included in the meta-analysis did not consider the effect of some clinical characteristics, such as the size of PFO and the risk of venous thrombosis and, consequently, paradoxical emboli. Before finding answers to the right medical therapy after cryptogenic stroke in the presence of PFO, we might have some further questions to ask ourselves.