Filippo Angelini1, Federico Fortuni2, Georgios Tsivgoulis3,4, Giancarlo Agnelli5, Pier Paolo Bocchino6, Luca Franchin6, Ovidio De Filippo6, Matteo Bellettini6, Fabrizio D'Ascenzo6, Gabriele Crimi2, Sergio Leonardi2,7, Gaetano M De Ferrari6, Maurizio Paciaroni5. 1. Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Torino, Italy. filippoangelinimd@gmail.com. 2. Division of Cardiology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy. 3. Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National & Kapodistrian University of Athens, Athens, Greece. 4. Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA. 5. Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, S. Maria della Misericordia Hospital, Perugia, Italy. 6. Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Torino, Italy. 7. Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
Abstract
PURPOSE: Patients with patent foramen ovale (PFO) and cryptogenic ischemic stroke (CS) are at risk for stroke recurrence. The optimal antithrombotic strategy in patients who undergo medical management is still debated. METHODS: We systematically searched the literature for studies that reported on cerebrovascular event recurrences and/or death in patients with PFO treated with oral anticoagulation (OAC) or antiplatelet therapy (APT) for secondary prevention of CS. The efficacy endpoints were stroke recurrence and the composite of stroke, transient ischemic attack or all-cause death. Major bleedings represented the safety endpoint. RESULTS: A total of 16 studies with 3953 patients (OAC = 1527, APT = 2426) were included. Weighted mean follow-up was 2.9 years. OAC was associated with a significant reduction in the risk of stroke compared with APT (RR 0.65; 95% CI 0.44-0.95; ARR 2%, NNT 49), while no difference was found regarding the composite outcome (RR 0.78; 95% CI 0.57-1.07) and the safety outcome (RR 1.57; 95% CI 0.85-2.90; p = 0.15). CONCLUSIONS: OAC was more effective than APT in reducing the risk of stroke recurrence in patients with PFO and CS, without a significant increase in the risk of major bleedings. Our findings support the need for further randomized data focused on the comparison of antithrombotic strategies in this setting.
PURPOSE: Patients with patent foramen ovale (PFO) and cryptogenic ischemic stroke (CS) are at risk for stroke recurrence. The optimal antithrombotic strategy in patients who undergo medical management is still debated. METHODS: We systematically searched the literature for studies that reported on cerebrovascular event recurrences and/or death in patients with PFO treated with oral anticoagulation (OAC) or antiplatelet therapy (APT) for secondary prevention of CS. The efficacy endpoints were stroke recurrence and the composite of stroke, transient ischemic attack or all-cause death. Major bleedings represented the safety endpoint. RESULTS: A total of 16 studies with 3953 patients (OAC = 1527, APT = 2426) were included. Weighted mean follow-up was 2.9 years. OAC was associated with a significant reduction in the risk of stroke compared with APT (RR 0.65; 95% CI 0.44-0.95; ARR 2%, NNT 49), while no difference was found regarding the composite outcome (RR 0.78; 95% CI 0.57-1.07) and the safety outcome (RR 1.57; 95% CI 0.85-2.90; p = 0.15). CONCLUSIONS: OAC was more effective than APT in reducing the risk of stroke recurrence in patients with PFO and CS, without a significant increase in the risk of major bleedings. Our findings support the need for further randomized data focused on the comparison of antithrombotic strategies in this setting.