Comparison of antithrombotic strategies in patients with cryptogenic stroke and patent foramen ovale: an updated meta-analysis

• Published in: Cardiovascular drugs and therapy 2021-10, Vol.35 (5), p.987-993
• Main Authors: Angelini, Filippo, Fortuni, Federico, Tsivgoulis, Georgios, Agnelli, Giancarlo, Bocchino, Pier Paolo, Franchin, Luca, De Filippo, Ovidio, Bellettini, Matteo, D’Ascenzo, Fabrizio, Crimi, Gabriele, Leonardi, Sergio, De Ferrari, Gaetano M., Paciaroni, Maurizio
• Format: Article
• Language: English
• Subjects: Anticoagulants; Anticoagulants - administration & dosage; Anticoagulants - adverse effects; Anticoagulants - therapeutic use; Antiplatelet therapy; Cardiology; Foramen Ovale, Patent - drug therapy; Foramen Ovale, Patent - epidemiology; Health risks; Hemorrhage - chemically induced; Humans; Ischemia; Ischemic Stroke - epidemiology; Medicine; Medicine & Public Health; Meta-analysis; Original Article; Patients; Platelet Aggregation Inhibitors - administration & dosage; Platelet Aggregation Inhibitors - adverse effects; Platelet Aggregation Inhibitors - therapeutic use; Recurrence; Risk; Safety; Stroke; Transient ischemic attack
• ISSN: 0920-3206; 1573-7241
• DOI: 10.1007/s10557-020-07068-9

Purpose Patients with patent foramen ovale (PFO) and cryptogenic ischemic stroke (CS) are at risk for stroke recurrence. The optimal antithrombotic strategy in patients who undergo medical management is still debated. Methods We systematically searched the literature for studies that reported on cerebrovascular event recurrences and/or death in patients with PFO treated with oral anticoagulation (OAC) or antiplatelet therapy (APT) for secondary prevention of CS. The efficacy endpoints were stroke recurrence and the composite of stroke, transient ischemic attack or all-cause death. Major bleedings represented the safety endpoint. Results A total of 16 studies with 3953 patients (OAC = 1527, APT = 2426) were included. Weighted mean follow-up was 2.9 years. OAC was associated with a significant reduction in the risk of stroke compared with APT (RR 0.65; 95% CI 0.44–0.95; ARR 2%, NNT 49), while no difference was found regarding the composite outcome (RR 0.78; 95% CI 0.57–1.07) and the safety outcome (RR 1.57; 95% CI 0.85–2.90; p  = 0.15). Conclusions OAC was more effective than APT in reducing the risk of stroke recurrence in patients with PFO and CS, without a significant increase in the risk of major bleedings. Our findings support the need for further randomized data focused on the comparison of antithrombotic strategies in this setting.