Expert consensus statement for the management of patients with embolic stroke of undetermined source and patent foramen ovale: A clinical guide by the working group for stroke of the Hellenic Society of Cardiology and the Hellenic Stroke Organization

Ntaios, Georgios; Vavouranakis, Emmanouil; Nikas, Dimitrios; Katsimagklis, Georgios; Koroboki, Eleni; Manolis, Antonis S; Milionis, Haralampos; Papadopoulos, Konstantinos; Sideris, Skevos; Spengos, Konstantinos; Toutouzas, Konstantinos; Tziakas, Dimitrios; Vassilopoulou, Sofia; Kanakakis, Ioannis; Vemmos, Konstantinos; Tsioufis, Κonstantinos

doi:10.1016/j.hjc.2020.02.001

Cited by 7 publications

(8 citation statements)

References 37 publications

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“…This finding should be attributed to the pragmatic nature and, in particular, to the fact that the detection of PFO in patients older than 60 years is of little importance in the management of most patients according to current knowledge. 8,9 Atrial cardiopathy was defined based on clinically relevant electro-and echocardiography markers of left atrial enlargement and dysfunction, while several conditions or serum biomarkers possibly related to atrial cardiopathy were not included in the analysis. The strengths of the analysis include the large number of consecutive ESUS patients, its multicenter design, the definition of ESUS according to widely accepted criteria, 1 and the definition of atrial cardiopathy by multiple recommended criteria.…”

Section: Discussionmentioning

confidence: 99%

“…[23][24][25][26] With regard to PFO, although it is now clear that percutaneous closure of PFO reduces the risk of stroke recurrence in patients younger than 60 years of age, there are many other questions still open, like whether percutaneous PFO closure is beneficial in older patients, and whether the echocardiographic characteristics of the PFO (e.g., the size of the shunt and the presence of atrial septal aneurysm) and the clinical characteristics of the patient (e.g., the RoPE score) could identify a subpopulation which may benefit by percutaneous PFO closure beyond current recommendations. 8,9,[27][28][29] Ongoing and future research will hopefully address many of these open questions and facilitate the improvement of outcomes in this population.…”

Section: Thrombosis and Haemostasismentioning

confidence: 99%

“…7 In addition, echocardiographic parameters such as PFOs with large shunt or with atrial septal aneurysm are considered to be associated with higher embolic risk. 8,9 Atrial cardiopathy and PFO require different secondary prevention strategies, but such a tailored approach needs to take into consideration the causal relationship between these two potential sources and the ischemic stroke, and the degree of overlap between the two pathologies. In this context, we aimed to investigate the relation between atrial cardiopathy and likely pathogenic PFO in patients with ESUS.…”

Section: Introductionmentioning

confidence: 99%

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Atrial Cardiopathy and Likely Pathogenic Patent Foramen Ovale in Embolic Stroke of Undetermined Source

et al. 2020

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Background Atrial cardiopathy and likely pathogenic patent foramen ovale (PFO) are two potential embolic sources in patients with embolic stroke of undetermined source (ESUS). The relationship between these two mechanisms among ESUS patients remains unclear. Methods Atrial cardiopathy was defined as increased left atrial diameter index (> 23 mm/m2) or left atrial volume index (> 34 mL/m2), or PR prolongation (≥ 200 ms), or presence of supraventricular extrasystoles in the electrocardiograms performed during hospitalization for the index stoke. The presence of PFO was assessed by transthoracic echocardiography with microbubble test or by transesophageal echocardiography. The presence of PFO was considered as likely pathogenic if the Risk of Paradoxical Embolism score was 7 to 10. Results Among 367 ESUS patients with available information about the presence of PFO and the presence of atrial cardiopathy (median age: 61 years, 40.6% women), likely pathogenic PFO was diagnosed in 62 (16.9%) and atrial cardiopathy in 122 (33.2%). Only 4 patients (1.1%) had both likely pathogenic PFO and atrial cardiopathy. The prevalence of atrial cardiopathy was lower in patients with likely pathogenic PFO (6.5%) compared with patients with likely incidental PFO (31.2%) or without PFO (40.6%) (Pearson's chi-square test: 26.08, p < 0.001; adjusted odds ratio [OR]: 0.28, 95% confidence interval [CI]: 0.09–0.86). The prevalence of likely pathogenic PFO was lower in patients with atrial cardiopathy compared with patients without atrial cardiopathy (3.3% vs. 23.7%, respectively [Pearson's chi-square test: 24.13, p < 0.001; adjusted OR: 0.2, 95% CI: 0.02–0.6]). Conclusion The presence of atrial cardiopathy is inversely related to the presence of likely pathogenic PFO in patients with ESUS.

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Section: Discussionmentioning

confidence: 99%

Section: Thrombosis and Haemostasismentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Atrial Cardiopathy and Likely Pathogenic Patent Foramen Ovale in Embolic Stroke of Undetermined Source

et al. 2020

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“…Fourth, this TCD bubble test for RLS should be interpreted only as a second line to a classical workup flowchart for syncope at present. The prevalence of RLS (15-25%) is also high in the asymptomatic population (19). Therefore, our findings should not prevent diagnosis of other severe causes that need to be promptly addressed.…”

Section: Discussionmentioning

confidence: 67%

“…It is estimated that RLS can be found in 15-25% of the general population (19); however, the prevalence of RLS in patients with unexplained syncope is still unclear. The clinical relevance of RLS mainly involves migraine and cryptogenic stroke (ischemic stroke with unknown causes) (7,8,20).…”

Section: Sample Size Calculationmentioning

confidence: 99%

Right-to-left shunts in unexplained syncope: an age- and sex-matched case-control study

Liu¹,

Chen²,

Gong³

et al. 2022

Quant Imaging Med Surg

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Background: Syncope is common, but there is no clear cause for half of the patients diagnosed with syncope. Although suspected, there is limited evidence that right-to-left shunt (RLS) is related to syncope.This matched case-control study investigated the association between RLS (exposure) and unexplained syncope (outcome).Methods: Consecutive unexplained syncope cases, together with age-and gender-matched controls who did not have syncope were recruited from 2009 to 2010 in the first affiliated hospital of Nanjing Medical University. A transcranial Doppler ultrasonography bubble test was applied for the ascertainment of RLS.The degree of RLS was categorized into grades 0 to 4 according to the number of microemboli, which were no shunt, <10 microbubbles (MB), 11-25 MB, >25 MB single spots pattern, and MB in a shower/curtain pattern, respectively. Cerebral small vessel diseases (SVD), including white matter hyperintensity, lacunes, and enlarged perivascular spaces, were rated on Magnetic resonance imaging. Conditional logistic regression was used to examine the association between RLS and unexplained syncope.Results: A total of 52 cases and 52 age-and gender-matched controls were recruited. Among the 52 cases, 4 patients had a history of migraine. Among the 104 participants, 68 had no RLS; 13, 4, 7, and 12 presented with <10, 11-25, >25, and shower/curtain MB, respectively. The incidence of any RLS (Grade 1-4) was 48.1% (25/52) in cases and 21.2% (11/52) in controls (P=0.004). Conditional logistic regression showed an association between RLS and unexplained syncope [odds ratio (OR) =1.988; 95% confidence interval (CI):1.233 to 3.205; P=0.005] adjusting for SVD burden. Further analysis revealed a large OR between severe RLS (Grade 3-4) and unexplained syncope (OR =8.699; P=0.006). Furthermore, SVD burden was shown to be associated with syncope.Conclusions: This matched case-control study showed a significant association between RLS and unexplained syncope, independent of cerebral SVD. Prospective studies are needed to confirm the causal relationship.

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Nickel Hypersensitivity to Atrial Septal Occluders: Smoke Without Fire?

Toutouzas

Drakopoulou

Gregoriou

et al. 2021

Clinic Rev Allerg Immunol

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Expert consensus statement for the management of patients with embolic stroke of undetermined source and patent foramen ovale: A clinical guide by the working group for stroke of the Hellenic Society of Cardiology and the Hellenic Stroke Organization

Cited by 7 publications

References 37 publications

Atrial Cardiopathy and Likely Pathogenic Patent Foramen Ovale in Embolic Stroke of Undetermined Source

Atrial Cardiopathy and Likely Pathogenic Patent Foramen Ovale in Embolic Stroke of Undetermined Source

Right-to-left shunts in unexplained syncope: an age- and sex-matched case-control study

Nickel Hypersensitivity to Atrial Septal Occluders: Smoke Without Fire?

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