Key result
The presence of a patent foramen ovale in largely anticoagulated patients with atrial fibrillation was not associated with an increased risk of ischaemic stroke (HR 0.82; 95% CI 0.57-1.18).
Why the study?
It was unknown whether concomitant patent foramen ovale adds incremental risk of ischaemic stroke to that linked to atrial fibrillation alone.
Does the presence of a patent foramen ovale increase the risk of ischaemic stroke in anticoagulated patients with atrial fibrillation?
Cohort (n=3,069)
Does the presence of a patent foramen ovale increase the risk of ischaemic stroke in anticoagulated patients with atrial fibrillation?
Hazard Ratio: 0.82 (95% CI 0.57–1.18)
In anticoagulated patients with atrial fibrillation, the presence of a PFO is not associated with an increased risk of ischaemic stroke overall, although a right-to-left shunt may increase risk.
Does not support routine PFO evaluation or closure in anticoagulated AF; leaves open its role without anticoagulation.
Objective: Previous studies have postulated a causal role of patent foramen ovale (PFO) in the aetiology of embolic stroke in the general population. We hypothesised that the presence of concomitant PFO and atrial fibrillation (AF) will add incremental risk of ischaemic stroke to that linked to AF alone. Methods: We analysed data on 3069 consecutive patients (mean age 69.4±12.2 years; 67.1% men) undergoing transoesophageal echocardiography-guided electrical cardioversion (ECV) for AF between May 2000 and March 2012. PFO was identified by colour Doppler and agitated saline contrast study. All patients were followed up after ECV for first documentation of ischaemic stroke. Outcomes were compared using Cox regression models. Results: The prevalence of PFO was 20.0% and the shunt direction was left-to-right in the majority of patients (71.4%). Patients with PFO had a higher frequency of obstructive sleep apnoea (21.7% vs 17.1%, p=0.01) and higher mean peak left atrial appendage emptying velocity (38.3±21.8 vs 36.1±20.4 cm/s; p=0.04) compared with those without PFO. Otherwise, baseline characteristics were similar between groups. During a mean follow-up period of 7.3±4.6 years, 214 patients (7.0%) had ischaemic stroke. Multivariable analysis showed no significant association between PFO and ischaemic stroke (HR, 0.82 (95% CI 0.57 to 1.18)). PFO shunt direction was strongly associated with stroke: HR, 1.91 (95% CI 1.16 to 3.16) for right-to-left shunt and HR, 0.58 (95% CI 0.36 to 0.93) for left-to-right shunt. Conclusions: The presence of concurrent PFO in this largely anticoagulated group of patients with AF was not associated with increased risk of ischaemic stroke.
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Melduni et al. (2020) conducted a cohort in atrial fibrillation (n=3,069). Patent foramen ovale vs. Absence of patent foramen ovale was evaluated on ischaemic stroke (HR 0.82, 95% CI 0.57 to 1.18). The presence of a patent foramen ovale in largely anticoagulated patients with atrial fibrillation was not associated with an increased risk of ischaemic stroke (HR 0.82; 95% CI 0.57-1.18).
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