PREVENTING STROKE RECURRENCE IN PATIENTS WITH PATENT FORAMEN OVALE - ANTITHROMBOTIC THERAPY, FORAMEN CLOSURE, OR THERAPEUTIC ABSTENTION - ADECISION-ANALYTIC PERSPECTIVE

Emphasis on the role of patent foramen ovale as a potential risk facto r for ischemic paradoxical stroke has recently increased. Current ther apeutic options for secondary stroke prevention include long-term anti thrombotic therapies and invasive closure of the defect, but selective indications have not been evaluated. Therefore we developed a Markov- based decision analysis model for a hypothetical cohort of patients 55 years of age with presumed paradoxical embolism, measuring for each t herapy the risks of stroke recurrence, treatment-related complications , and death after 5 years and the quality-adjusted life-years. Over a wide range of stroke risk recurrence (0.8% per year to 7% per year), t he gain provided by closure of the defect exceeded the one obtained by other therapeutic options. When the risk exceeded 0.8% per year and 1 .4% per year, respectively, this was also verified for anticoagulation and antiplatelet therapies compared with therapeutic abstention. Ther apeutic abstention was the preferred strategy under 0.8% per year. Sen sitivity analyses identified key parameters influencing the choice of therapy. These included estimates of stroke recurrence, bleeding rates , surgery-related case fatality rates, and age. Considering the risks of treatment and the devastating consequences of a recurrent stroke, o ur model suggests that if the estimated risk of paradoxical stroke rec urrence is >0.8% per year, therapeutic abstention becomes the worst op tion. Above this threshold secondary stroke prevention with anticoagul ation therapy or surgical closure of the defect is the preferred strat egy, and assessment of both the risk of stroke recurrence and the risk related to therapeutic options should guide individual therapeutic de cision making.