Abstract
Objective A patent foramen ovale (PFO) is frequently associated with cryptogenic stroke in
the young. Endovascular closure is superior to antithrombotic treatment in prevention
of recurrence, but in the presence of a concomitant thrombophilia, the best preventive
strategy is unknown. This review investigates if thrombophilia increases the risk
of recurrence in patients with cryptogenic stroke and PFO and attempts to evaluate
the best antithrombotic strategy after PFO closure in these patients.
Methods Medline, Embase, and Web of Science were searched until April 2018. Study quality
was assessed by the National Heart, Lung and Blood Institute Quality assessment tool.
Odds ratio (OR) and hazard ratio for recurrence were pooled in a random effect model
stratified by secondary preventive strategy.
Results Eleven studies were included. Inherited or acquired thrombophilia was associated
with an increased risk of recurrence (OR = 2.41, 95% confidence interval [CI]: 1.44–4.06).
Looking only at patients treated with PFO closure, the risk of recurrence just lost
significance (OR = 2.07, 95% CI: 0.95–4.48). The antithrombotic treatment after PFO
closure was heterogeneous and recurrent events occurred in patients with both inherited
and acquired thrombophilia treated by antiplatelet as well as anticoagulant therapy.
Conclusion Thrombophilia is associated with an increased risk of recurrence in patients with
PFO and cryptogenic stroke, which may persist after PFO closure. This suggests a need
for antithrombotic therapy after PFO closure. Study heterogeneity precludes strong
conclusions on antithrombotic treatment, but life-long antiplatelet therapy to patients
without preexisting indication for anticoagulant therapy seems reasonable.
Keywords
patent foramen ovale - thrombophilia - stroke
