Neurologists and Cardiologists Differ on Management of PFO


MIAMI BEACH — Neurologists are less likely than cardiologists to favor closure of patent foramen ovale in an attempt to prevent stroke, according to survey results presented at the annual meeting of the American Academy of Neurology.

Although there is a higher prevalence of patent foramen ovale (PFO) among patients who experience a stroke when no other cause is identified, studies have yet to prove that percutaneous closure makes a difference in outcomes. “It is not yet proven that closing the PFO through cardiac catheterization is better than medication,” Steven R. Messe, M.D., told this newspaper during an interview at his poster presentation.

To compare how different specialists manage these patients, Dr. Messe and his colleagues surveyed 129 cardiologists and 108 neurologists. All the physicians were investigators in the CLOSURE-I trial, a study comparing percutaneous closure with medical therapy.

The response rate was 39.5%, with 36% of cardiologists and 44% of neurologists answering the survey. The 17-item questionnaire assessed practice regarding PFO diagnosis, high-risk characteristics, treatment choices, and alternative indications for PFO closure.

According to the survey, 78% of the cardiologists and 65% of the neurologists believe that PFO is relevant to future stroke risk regardless of age.

Despite insufficient outcome data, cardiologists said they recommend percutaneous closure for 55% of patients with a PFO, compared with neurologists, who recommend it for only 20%.

“Closure in general is being used frequently without data at this point, for one in five neurology patients,” said Dr. Messe, attending neurologist, Hospital of the University of Pennsylvania, Philadelphia.

“Interventional cardiologists do the procedure, and they are eager to do it. Neurologists are more conservative,” Dr. Messe said.

A minority, 9% of cardiologists and 2% of neurologists, have recommended closure for asymptomatic PFO patients. A total of 24% of cardiologists and 6% of neurologists would close a patent foramen ovale in a patient who scuba dives, according to the survey. In addition, 14% of cardiologists but no neurologists said they have recommended PFO closure for migraine treatment.

Neurologists prescribe antiplatelet therapy, such as warfarin, for 49% of patients with a PFO. Cardiologists prescribe the same medications for 26% of patients.

Most neurologists may be waiting for more evidence of improved outcomes, Dr. Messe said. “I think neurologists will be excited to refer PFO patients for closure once it's proven to make a difference in prevention of stroke.”

Recommended Reading

Warfarin Less Effective in Real Life Than in Trials
MDedge Cardiology
MRI Buys Time for Thrombolysis of Acute Stroke
MDedge Cardiology
Lower Dose of TPA May Suffice for Acute Stroke
MDedge Cardiology
Aspirin Is Better Than Warfarin for Intracranial Arterial Stenosis Patients
MDedge Cardiology
Emboli Filters Prevent Stroke During Carotid Stenting
MDedge Cardiology