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(Stroke. 2009;40:2349.)
© 2009 American Heart Association, Inc.

Original Contributions

Patent Foramen Ovale in Cryptogenic Stroke

Incidental or Pathogenic?

Alawi A. Alsheikh-Ali, MD; David E. Thaler, MD, PhD David M. Kent, MD, MS

From the Institute for Clinical Research and Health Policy Studies (A.A.A., D.M.K.), the Division of Cardiology, Department of Medicine (A.A.A.), and the Department of Neurology (D.E.T.), Tufts Medical Center/Tufts University School of Medicine, Boston, Mass.

Correspondence to David M. Kent, MD, MS, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Box #63, 800 Washington Street, Boston, MA 02111. E-mail dkent1{at}tuftsmedicalcenter.org

Background and Purpose— Patent foramen ovale (PFO) is significantly associated with cryptogenic stroke (CS). However, even in patients with CS, a PFO can be an incidental finding. We sought to estimate the probability that a PFO in a patient with CS is incidental.

Methods— A systematic search identified 23 case-control studies examining the prevalence of PFO in patients with CS versus control subjects with stroke of known cause. Using simple assumptions and Bayes’ theorem, we calculated the probability a PFO is incidental in patients with CS. Random effects meta-analyses estimated the odds ratio (OR) of a PFO in CS versus control subjects in different age populations, with or without atrial septal aneurysms, and were used to summarize across studies the probability that a PFO in CS is incidental.

Results— The summary OR (95% CIs) for PFO in CS versus control subjects was 2.9 (CI, 2.1 to 4.0). The corresponding ORs for young and old patients (< or 55 years) were 5.1 (3.3 to 7.8) and 2.0 (>1.0 to 3.7), respectively. The corresponding probabilities that a PFO in patients with CS is incidental were 33% (28% to 39%) in age-inclusive studies, 20% (16% to 25%) in younger patients, and 48% (34% to 66%) in older patients. These probabilities were much lower when an atrial septal aneurysm was present.

Conclusions— In patients with otherwise CS, approximately one third of discovered PFOs are likely to be incidental and hence not benefit from closure. This probability is sensitive to patient characteristics such as age and the presence of an atrial septal aneurysm, suggesting the importance of patient selection in therapeutic decision-making.

Key Words: patent foramen ovale • risk factors for stroke • secondary stroke prevention