To identify the proportion of cryptogenic stroke patients with PFO at our institution that were advised medical management over PFO closure prior to the publication of CLOSE, RESPECT, and REDUCE in September 2017.

In 2017, three randomized controlled trials of patients with cryptogenic embolic stroke and higher-risk PFO demonstrated reduced recurrent stroke in patients undergoing PFO closure.  Ascertaining the number of patients who would benefit from PFO closure, but were previously recommended medical management, is an important secondary stroke prevention initiative.

We retrospectively reviewed the electronic medical record of patients evaluated in our institution’s stroke clinic over the past 5 years. We abstracted patient demographics, stroke subtype, ROPE score, and PFO characteristics.  We subsequently reassessed if the initial secondary stroke prevention strategy (closure vs. medical management) remained optimal in light of the recent trial evidence.

262 stroke patients were reviewed. Thirty-four (13%) patients had PFO (52% male, mean age 51.8 years [SD ±16.4]) and the majority were treated with antiplatelet therapy (94%). Of these patients 19 (56%) had cryptogenic embolic stroke.  Eight (24%) patients had high risk PFO and 6 (18%) patients met criteria for PFO closure when applying generalized inclusion criteria derived from CLOSE, RESPECT, and REDUCE.  For every 44 patients we screened, one patient that would benefit from PFO closure was identified.

Recent clinical trial evidence supports PFO closure in appropriately selected patients.  For every 44 patients screened, we identified one additional patient previously recommended medical management that would benefit from PFO closure for secondary stroke prevention.  The ‘number needed to screen’ in other clinical settings is likely to be lower, due to an unexpectedly low rate of PFO in our clinic.