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PFO and Ischemic Stroke in Patients With Pulmonary Embolism
Study Questions:
Is recent ischemic stroke more common in acute pulmonary embolism (PE) patients with patent foramen ovale (PFO) compared to acute PE patients without PFO?
Methods:
This is a cross-sectional study of patients ≥18 years old with an acute (<3 days from diagnosis), symptomatic PE consecutively enrolled at four hospitals in France. All patients underwent a transthoracic echocardiogram (TTE) (with saline injection at rest and during Valsalva) and magnetic resonance imaging (MRI) of the brain within 7 days of enrollment. The primary outcome was diagnosis of ischemic stroke based on positive MRI.
Results:
A total of 315 patients were included in the primary outcome analysis, including 36 (11%) with PFO. No differences were observed between the PFO and non-PFO subjects in general characteristics, including PE severity and cardiovascular risk factors. Ischemic stroke was observed in 24 of the 315 (7.6%) patients. The diagnosis of stroke occurred more frequently in the PFO group (21.4%) than in the non-PFO group (5.5%) (relative risk, 3.90; 95% confidence interval [CI], 1.62-8.67).
Conclusions:
In this cross-sectional study, the frequency of recent symptomatic or silent ischemic stroke was almost four times higher in acute PE patients with PFO than in those without PFO.
Perspective:
The results of this study are interesting but unlikely to change clinical practice (i.e., will not lead to increased screening of acute PE patients for PFO) given that the best management of PFO in patients without stroke (in this study, 92.4% of subjects) or in patients with silent cerebral ischemia remains uncertain. As for acute PE patients with stroke symptoms (in this study, 2.5% of subjects), these patients generally already undergo a TTE with bubble study as part of their workup for stroke etiology. Of note, it is unclear why the prevalence of PFO among this study’s subjects (13%) was lower than the prevalence of PFO generally described in the population (~20%).
Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Prevention, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Quality Improvement, Echocardiography/Ultrasound, Magnetic Resonance Imaging
Keywords: Brain Ischemia, Cerebral Infarction, Echocardiography, Foramen Ovale, Patent, Magnetic Resonance Imaging, Heart Defects, Congenital, Pulmonary Embolism, Risk Factors, Secondary Prevention, Stroke, Vascular Diseases
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