Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline

doi:10.1136/bmj.k2515

Practice Guideline

. 2018 Jul 25:362:k2515.

doi: 10.1136/bmj.k2515.

Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline

Ton Kuijpers¹, Frederick A Spencer², Reed A C Siemieniuk^{3

4}, Per O Vandvik^{5

6}, Catherine M Otto⁷, Lyubov Lytvyn², Hassan Mir², Albert Y Jin⁸, Veena Manja⁹, Ganesan Karthikeyan¹⁰, Elke Hoendermis¹¹, Janet Martin¹², Sebastian Carballo¹³, Martin O'Donnell¹⁴, Trond Vartdal¹⁵, Christine Baxter¹⁶, Bray Patrick-Lake¹⁷, Joanie Scott¹⁸, Thomas Agoritsas^{3

19}, Gordon Guyatt^{2

3}

Affiliations

¹ Department of guideline development and research, Dutch College of General Practitioners, Utrecht, The Netherlands t.kuijpers@nhg.org.
² McMaster University, Hamilton, Canada.
³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8.
⁴ Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
⁵ Norwegian Institute of Public Health, Oslo, Norway.
⁶ Department of Medicine, Innlandet Hospital Trust - division Gjøvik, Norway.
⁷ University of Washington, Seattle, District of Colombia, USA.
⁸ Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
⁹ University of California Davis, Sacramento, CA, USA.
¹⁰ All India Institute of Medical Sciences, New Delhi, India.
¹¹ University Medical Center of Groningen, Groningen, The Netherlands.
¹² Departments of Anesthesia & Perioperative Medicine, and Epidemiology & Biostatistics, Western University, London, Canada.
¹³ Division General Internal Medicine, University Hospitals of Geneva, CH-1211, Geneva, Switzerland.
¹⁴ NUI Galway, Galway, Ireland.
¹⁵ Oslo University Hospital, Oslo, Norway.
¹⁶ Las Vegas, Nevada, USA.
¹⁷ Boulder, Colorado, USA.
¹⁸ Welwyn, Hertfordshire, UK.
¹⁹ Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland.

PMID: 30045912
PMCID: PMC6058599
DOI: 10.1136/bmj.k2515

Practice Guideline

Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline

Ton Kuijpers et al. BMJ. 2018.

. 2018 Jul 25:362:k2515.

doi: 10.1136/bmj.k2515.

Authors

Affiliations

¹ Department of guideline development and research, Dutch College of General Practitioners, Utrecht, The Netherlands t.kuijpers@nhg.org.
² McMaster University, Hamilton, Canada.
³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8.
⁴ Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
⁵ Norwegian Institute of Public Health, Oslo, Norway.
⁶ Department of Medicine, Innlandet Hospital Trust - division Gjøvik, Norway.
⁷ University of Washington, Seattle, District of Colombia, USA.
⁸ Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
⁹ University of California Davis, Sacramento, CA, USA.
¹⁰ All India Institute of Medical Sciences, New Delhi, India.
¹¹ University Medical Center of Groningen, Groningen, The Netherlands.
¹² Departments of Anesthesia & Perioperative Medicine, and Epidemiology & Biostatistics, Western University, London, Canada.
¹³ Division General Internal Medicine, University Hospitals of Geneva, CH-1211, Geneva, Switzerland.
¹⁴ NUI Galway, Galway, Ireland.
¹⁵ Oslo University Hospital, Oslo, Norway.
¹⁶ Las Vegas, Nevada, USA.
¹⁷ Boulder, Colorado, USA.
¹⁸ Welwyn, Hertfordshire, UK.
¹⁹ Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland.

PMID: 30045912
PMCID: PMC6058599
DOI: 10.1136/bmj.k2515

No abstract available

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Conflict of interest statement

Competing interests: All authors have completed the BMJ Rapid Recommendations interests disclosure form, and a detailed description of all disclosures is reported in appendix 2 on bmj.com. No authors had relevant financial interests. They declared the following intellectual interests: Elke Hoendermis is co-author of national recommendations on PFO closure and stroke on behalf of the working group of the Netherlands Society of Cardiology. Fred Spencer has published systematic review and meta-analysis on this topic. No panel member had any other intellectual conflict to disclose. As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any financial conflict of interest. Professional and academic interests are minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions.

Figures

**Fig 2**
Characteristics of patients and trials included in systematic review of the effects of percutaneous closure followed by antiplatelet therapy versus antiplatelet or anticoagulation therapy alone in patients with patent foramen ovale (PFO) and cryptogenic stroke. Evidence used from 6 randomised clinical trials (plus 2 further trials for comparison of antiplatelets and anticoagulants34 35)

**Fig 3**
Practical issues about use of percutaneous closure followed by antiplatelet therapy versus antiplatelet or anticoagulation therapy alone in patients with patent foramen ovale (PFO) and cryptogenic stroke

See this image and copyright information in PMC

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References

1. Mir H, Siemieniuk R, Ge L., et al. Percutaneous closure plus antiplatelet therapy versus antiplatelet or anticoagulation therapy alone in patients with patent foramen ovale and cryptogenic stroke: a systematic review and network meta-analysis incorporating complementary external evidence. BMJ Open 2018;0:e023761 10.1136/bmjopen-2018-023761. - DOI - PMC - PubMed
1. Mas JL, Derumeaux G, Guillon B, et al. CLOSE Investigators Patent foramen ovale closure or anticoagulation vs antiplatelets after stroke. N Engl J Med 2017;377:1011-21. 10.1056/NEJMoa1705915 - DOI - PubMed
1. Saver JL, Carroll JD, Thaler DE, et al. RESPECT Investigators Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017;377:1022-32. 10.1056/NEJMoa1610057 - DOI - PubMed
1. Søndergaard L, Kasner SE, Rhodes JF, et al. Gore REDUCE Clinical Study Investigators Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017;377:1033-42. 10.1056/NEJMoa1707404 - DOI - PubMed
1. Siemieniuk RA, Agoritsas T, Macdonald H, Guyatt GH, Brandt L, Vandvik PO. Introduction to BMJ Rapid Recommendations. BMJ 2016;354:i5191. 10.1136/bmj.i5191 - DOI - PubMed

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[1] Mir H, Siemieniuk R, Ge L., et al. Percutaneous closure plus antiplatelet therapy versus antiplatelet or anticoagulation therapy alone in patients with patent foramen ovale and cryptogenic stroke: a systematic review and network meta-analysis incorporating complementary external evidence. BMJ Open 2018;0:e023761 10.1136/bmjopen-2018-023761. - DOI - PMC - PubMed

[2] Mir H, Siemieniuk R, Ge L., et al. Percutaneous closure plus antiplatelet therapy versus antiplatelet or anticoagulation therapy alone in patients with patent foramen ovale and cryptogenic stroke: a systematic review and network meta-analysis incorporating complementary external evidence. BMJ Open 2018;0:e023761 10.1136/bmjopen-2018-023761. - DOI - PMC - PubMed

[3] Mas JL, Derumeaux G, Guillon B, et al. CLOSE Investigators Patent foramen ovale closure or anticoagulation vs antiplatelets after stroke. N Engl J Med 2017;377:1011-21. 10.1056/NEJMoa1705915 - DOI - PubMed

[4] Mas JL, Derumeaux G, Guillon B, et al. CLOSE Investigators Patent foramen ovale closure or anticoagulation vs antiplatelets after stroke. N Engl J Med 2017;377:1011-21. 10.1056/NEJMoa1705915 - DOI - PubMed

[5] Saver JL, Carroll JD, Thaler DE, et al. RESPECT Investigators Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017;377:1022-32. 10.1056/NEJMoa1610057 - DOI - PubMed

[6] Saver JL, Carroll JD, Thaler DE, et al. RESPECT Investigators Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017;377:1022-32. 10.1056/NEJMoa1610057 - DOI - PubMed

[7] Søndergaard L, Kasner SE, Rhodes JF, et al. Gore REDUCE Clinical Study Investigators Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017;377:1033-42. 10.1056/NEJMoa1707404 - DOI - PubMed

[8] Søndergaard L, Kasner SE, Rhodes JF, et al. Gore REDUCE Clinical Study Investigators Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017;377:1033-42. 10.1056/NEJMoa1707404 - DOI - PubMed

[9] Siemieniuk RA, Agoritsas T, Macdonald H, Guyatt GH, Brandt L, Vandvik PO. Introduction to BMJ Rapid Recommendations. BMJ 2016;354:i5191. 10.1136/bmj.i5191 - DOI - PubMed

[10] Siemieniuk RA, Agoritsas T, Macdonald H, Guyatt GH, Brandt L, Vandvik PO. Introduction to BMJ Rapid Recommendations. BMJ 2016;354:i5191. 10.1136/bmj.i5191 - DOI - PubMed

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Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline

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Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline

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Conflict of interest statement

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