Background and Purpose: Patent foramen ovale (PFO) may increase the risk of embolic
stroke of undetermined source (ESUS). Guidelines suggest anticoagulation may be more
effective than antiplatelets in preventing stroke in patients with ESUS and PFO when
interventional closure is not performed. Methods: Patients with ESUS randomized to
dabigatran (150/110 mg BID) or aspirin (100 mg QD) from the RE-SPECT ESUS study (Randomized,
Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and
Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic
Acid in Patients With Embolic Stroke of Undetermined Source) were included. The rate
of recurrent stroke (primary end point) and ischemic stroke was reported for patients
with and without baseline PFO. A meta-analysis comparing the effects of anticoagulant
and antiplatelet therapy on ischemic stroke in patients with PFO was updated to include
RE-SPECT ESUS. Results: PFO was present in 680 of 5388 (12.6%) patients with documented
PFO status. The risk of recurrent stroke with dabigatran versus aspirin was similar
in patients with and without PFO (P for interaction, 0.8290). In patients with PFO,
the meta-analysis found no statistically significant difference between anticoagulant
and antiplatelet therapy (odds ratio, 0.70 [95% CI, 0.43-1.14]) for ischemic stroke.
Conclusions: There is insufficient evidence to recommend anticoagulation over antiplatelet
therapy for patients with ESUS and a PFO. More data are needed to guide antithrombotic
therapy in this population. Registration: URL: . Unique identifier: NCT02239120.
