Abstract
Dear Professor Lees,
With great interest, we have read the new ‘European Stroke Organisation (ESO) guideline on the diagnosis and management of patent foramen ovale (PFO) after stroke’ published in the European Stroke Journal. 1 We congratulate the authors for having gathered, analysed and summarised current evidence in a splendidly comprehensive way.
The guideline recommends PFO closure in PFO-associated stroke in selected patients in addition to antiplatelet therapy. The guideline, however, does not advise on timing. Of note, recent trials have incremented evidence that timing of secondary prevention measures contributes to their efficacy. In particular, early initiation may be beneficial. For example, the ESO guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack refers to studies suggesting benefit of early initiation of antiplatelets. 2 The ESO guideline on endarterectomy and stenting of carotid artery stenosis recommends early endarterectomy, ideally within 2 weeks of the last event. 3
Therefore, a statement on timing of PFO closure could be of great interest to the stroke community.
From our perspective, early closure of PFO may interfere with the thoroughness of diagnostic evaluation and may reduce the likelihood to find alternative stroke mechanisms. Our opinion is, that current evidence argues against a high risk of early stroke recurrence in patients with PFO-associated stroke 4 and that the relatively low risk allows waiting until a thorough diagnostic work-up has been completed. This should particularly include an ECG monitoring as recommended by current guidelines. 5
Practitioners should not rush into PFO closure. They should be assured that weighing advantages and disadvantages of PFO closure is not an urgent matter.
Kind regards,
Footnotes
Acknowledgements
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Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Ethical approval
None.
Guarantor
Christian H Nolte is the guarantor for this letter to the editor.
Contributorship
Christian H Nolte conceptualised the idea to write this letter to the editor, wrote the original draft and rewrote the draft after critical review by Heinrich J Audebert. Heinrich J Audebert critically reviewed the letter to the editor and gave commentaries for the revision. No additional person contributed to this letter to the editor.
