Recurrent stroke predictors differ in medically treated patients with pathogenic vs. other PFOs

David E Thaler; Robin Ruthazer; Christian Weimar; Jean-Louis Mas; Joaquín Serena; Emanuele Di Angelantonio; Federica Papetti; Shunichi Homma; Heinrich P Mattle; Krassen Nedeltchev; Marie-Luise Mono; Cheryl Jaigobin; Patrik Michel; Mitchell S V Elkind; Marco R Di Tullio; Jennifer S Lutz; John Griffith; David M Kent

doi:10.1212/WNL.0000000000000589

Recurrent stroke predictors differ in medically treated patients with pathogenic vs. other PFOs

Neurology. 2014 Jul 15;83(3):221-6. doi: 10.1212/WNL.0000000000000589. Epub 2014 Jun 13.

Authors

David E Thaler¹, Robin Ruthazer², Christian Weimar², Jean-Louis Mas², Joaquín Serena², Emanuele Di Angelantonio², Federica Papetti², Shunichi Homma², Heinrich P Mattle², Krassen Nedeltchev², Marie-Luise Mono², Cheryl Jaigobin², Patrik Michel², Mitchell S V Elkind², Marco R Di Tullio², Jennifer S Lutz², John Griffith², David M Kent²

Affiliations

¹ From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland. dthaler@tuftsmedicalcenter.org.
² From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.

Abstract

Objective: To examine predictors of stroke recurrence in patients with a high vs a low likelihood of having an incidental patent foramen ovale (PFO) as defined by the Risk of Paradoxical Embolism (RoPE) score.

Methods: Patients in the RoPE database with cryptogenic stroke (CS) and PFO were classified as having a probable PFO-related stroke (RoPE score of >6, n = 647) and others (RoPE score of ≤6 points, n = 677). We tested 15 clinical, 5 radiologic, and 3 echocardiographic variables for associations with stroke recurrence using Cox survival models with component database as a stratification factor. An interaction with RoPE score was checked for the variables that were significant.

Results: Follow-up was available for 92%, 79%, and 57% at 1, 2, and 3 years. Overall, a higher recurrence risk was associated with an index TIA. For all other predictors, effects were significantly different in the 2 RoPE score categories. For the low RoPE score group, but not the high RoPE score group, older age and antiplatelet (vs warfarin) treatment predicted recurrence. Conversely, echocardiographic features (septal hypermobility and a small shunt) and a prior (clinical) stroke/TIA were significant predictors in the high but not low RoPE score group.

Conclusion: Predictors of recurrence differ when PFO relatedness is classified by the RoPE score, suggesting that patients with CS and PFO form a heterogeneous group with different stroke mechanisms. Echocardiographic features were only associated with recurrence in the high RoPE score group.

Publication types

Research Support, N.I.H., Extramural

MeSH terms

Adult
Aged
Comorbidity
Databases, Factual
Embolism, Paradoxical / epidemiology*
Female
Follow-Up Studies
Foramen Ovale, Patent / classification
Foramen Ovale, Patent / diagnosis
Foramen Ovale, Patent / epidemiology*
Humans
Ischemic Attack, Transient / drug therapy
Ischemic Attack, Transient / epidemiology*
Male
Middle Aged
Predictive Value of Tests
Proportional Hazards Models
Recurrence
Risk Assessment
Stroke / drug therapy
Stroke / epidemiology*

Abstract

Publication types

MeSH terms

Grants and funding