Pill or plug? Rethinking secondary stroke prevention for PFO patients

Although patent foramen ovale (PFO) is common in the general population, it is notably more prevalent among patients with cryptogenic stroke (CS). The optimal management of PFO remains uncertain, with ongoing debate over the effectiveness of medical therapy compared to closure procedures. Medical treatments typically include antiplatelet drugs such as aspirin, clopidogrel, and dipyridamole, which aim to prevent arterial thrombus by inhibiting platelet aggregation, or anticoagulants like warfarin and direct oral anticoagulants (DOACs), which work on the coagulation cascade to reduce venous thrombus formation and embolic risk. In contrast, closure techniques aim to eliminate the anatomical conduit for emboli. Transcatheter closure using devices such as Amplatzer or Gore has demonstrated high success and safety rates, with evidence from trials including RESPECT, CLOSE, and REDUCE supporting reduced risk of recurrent CS. However, atrial fibrillation remains a common early complication. To address concerns about implants or nickel allergies, the NobleStitch EL suture system offers a promising device-free alternative. Patient selection for closure relies on risk stratification tools such as the RoPE and PASCAL scores, while contraindications include cardiac thrombus, endocarditis, or other potential embolic sources. Overall, current evidence indicates that closure may benefit carefully selected patients, yet medical therapy remains crucial, especially when closure is contraindicated or patient preference guides the decision. Further research is required to refine selection criteria, weigh long-term safety against efficacy, and clarify the comparative benefits of medical versus closure strategies. This review aims to synthesize the available evidence.