warfarin and Foramen-Ovale--Patent

Historically, because of the difficulty of using warfarin safely and effectively, many patients with cardioembolic stroke who should have been anticoagulated were instead given ineffective antiplatelet therapy (or no antithrombotic therapy). With the arrival of new oral anticoagulants that are not significantly more likely than aspirin to cause severe haemorrhage, everything has changed. Because antiplatelet agents are much less effective in preventing cardioembolic stroke, it is now more prudent to anticoagulate patients in whom cardioembolic stroke is strongly suspected. Recent advances include the recognition that intermittent atrial fibrillation is better detected with more prolonged monitoring of the cardiac rhythm, and that percutaneous closure of patent foramen ovale (PFO) may reduce the risk of stroke. However, because in most patients with stroke and PFO the PFO is incidental, this should be reserved for patients in whom paradoxical embolism is likely. A high shunt grade on transcranial Doppler saline studies, and clinical clues to paradoxical embolism, can help in appropriate selection of patients for percutaneous closure. For patients with atrial fibrillation who cannot be anticoagulated, ablation of the left atrial appendage is an emerging option. It is also increasingly recognised that high levels of homocysteine, often due to undiagnosed metabolic deficiency of vitamin B

Topics: Anticoagulants; Atrial Fibrillation; Cardiac Catheterization; Clinical Decision-Making; Embolic Stroke; Factor Xa Inhibitors; Fibrinolytic Agents; Foramen Ovale, Patent; Humans; Platelet Aggregation Inhibitors; Risk Assessment; Risk Factors; Treatment Outcome; Warfarin

Cryptogenic stroke is one-fourth among cerebral infarction, but most of them could be ascribed to embolic stroke. ESUS was proposed for unifying embolic stroke of undetermined sources by Hart et al. in 2014. The etiologies underlying ESUS included minor-risk potential cardioembolic sources, covert paroxysmal atrial fibrillation, cancer-associated coagulopathy and embolism, arteriogenic emboli, and paroxysmal embolism. Extensive evaluation including transesophageal echocardiography and cardiac monitoring for long time could identify the etiology of these patients. Although anti-platelet drug is recommended in ESUS in the current guideline, clinical trials are ongoing to determine the efficacy of non-vitamin K antagonist oral anticoagulant in ESUS patients.

Topics: Anticoagulants; Aspirin; Atrial Fibrillation; Blood Coagulation Disorders; Clinical Trials as Topic; Embolism; Foramen Ovale, Patent; Humans; Intracranial Embolism; Neoplastic Cells, Circulating; Platelet Aggregation Inhibitors; Stroke; Thrombolytic Therapy; Warfarin

Over the last two decades the interest on patent foramen ovale (PFO) as a cause of cardioembolism in cryptogenic stroke has tremendously increased, thanks to the availability of better techniques to diagnose cardiac right-to-left shunt by ultrasounds and of percutaneous means of PFO treatment with interventional techniques. Many studies have been published that have attempted to define diagnostic methodology, prognosis, and optimal treatment (pharmacological or percutaneous closure) of PFO patients with cryptogenic stroke. Unfortunately, even today, definitive evidence is still lacking, and clinical management is not consistent among cardiologists.. This review aims to evaluate the role of PFO in cryptogenic stroke, the diagnostic accuracy of transcranial Doppler, contrast transthoracic and transesophageal echocardiography in the diagnosis of left-fright shunt and PFO; and discuss the indications to medical treatment and percutaneous closure of PFO.. All studies published in the literature on PFO and cryptogenic stroke are considered and discussed.. We define an appropriate diagnostic and clinical management of PFO patients with cryptogenic stroke.. After many years of interest on PFO and many concluded studies, there are still no definitive data. However, we are on good track for an appropriate management of PFO patients and cryptogenic stroke.

Topics: Anticoagulants; Aspirin; Cardiac Catheterization; Echocardiography; Embolism, Paradoxical; Foramen Ovale, Patent; Humans; Recurrence; Risk Assessment; Stroke; Warfarin

The decline in stroke incidence and mortality in the U.S. over the past 20 years is reaching a plateau, and the number of strokes may actually start to increase as the population ages. However, recent clinical trials have demonstrated that there are numerous opportunities to improve stroke prevention strategies and also opportunities to effectively intervene in and treat acute strokes. For patients with diabetes and for those with prior strokes or transient ischemic attacks, it has become evident that aggressive low-density lipoprotein lowering with statin medications will decrease the risk for total and fatal strokes. Optimal anticoagulation and antiplatelet therapy for primary and secondary stroke prevention in atrial fibrillation is being carefully defined. With numerous novel factor Xa and direct thrombin inhibitor drugs completing phase III clinical trials, it is likely that additional oral anticoagulant drugs will be clinically available for stroke prevention soon. Additionally, a major clinical trial is nearing completion that may resolve the role of carotid stenting and carotid endarterectomy in primary and secondary stroke prevention. There are recent notable advances in the acute treatment of stroke. It is likely that the time window for thrombolysis for appropriate patients with strokes will be increased from 3 to 4.5 h, permitting the inclusion of more patients in this treatment approach. There is ongoing investigation of intra-arterial thrombolysis and of acute intra-arterial thrombus extraction for treatment of selected patients with strokes. Unlike the progress in treatment of ischemic strokes, treatment of hemorrhagic stroke is progressing more slowly.

Topics: Anticoagulants; Atrial Fibrillation; Brain Ischemia; Cholesterol, LDL; Diabetic Angiopathies; Endarterectomy, Carotid; Foramen Ovale, Patent; Heart Diseases; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypertension; International Normalized Ratio; Intracranial Hemorrhages; Stents; Stroke; Thrombectomy; Thrombolytic Therapy; Thrombosis; United States; Warfarin

We presented a patient suffered from stroke related to thalidomide therapy. The patient was a 74-year-old man who had about two-year history of multiple myeloma and treated with 100 mg of oral thalidomide daily. He was diagnosed as having cryptogenic stroke attributable to patent foramen ovale, when he admitted to our hospital with sudden onset left-side hemiparesis. Antiplatelet and neuroprotective therapies were commenced along with the use of elastic stocking to prevent further embolic event. Then, warfarin was selected as secondary prevention to reduce the risk of paradoxical embolism during thalidomide therapy. Although the risk of deep vein thrombosis on thalidomide therapy has been well documented, only a few cases have been noted documenting the risk of stroke during thalidomide therapy. We need to be careful about the risk of deep vein thrombosis on thalidomide therapy, even as monotherapy, and consider using anticoagulant therapy while prescribing thalidomide.

Topics: Aged; Anticoagulants; Aspirin; Embolism, Paradoxical; Foramen Ovale, Patent; Humans; Male; Multiple Myeloma; Neuroprotective Agents; Risk; Stockings, Compression; Stroke; Thalidomide; Venous Thrombosis; Warfarin

The prevalence of patent foramen ovale among patients with cryptogenic stroke is higher than that in the general population. Closure with a percutaneous device is often recommended in such patients, but it is not known whether this intervention reduces the risk of recurrent stroke.. We conducted a multicenter, randomized, open-label trial of closure with a percutaneous device, as compared with medical therapy alone, in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years.. A total of 909 patients were enrolled in the trial. The cumulative incidence (Kaplan-Meier estimate) of the primary end point was 5.5% in the closure group (447 patients) as compared with 6.8% in the medical-therapy group (462 patients) (adjusted hazard ratio, 0.78; 95% confidence interval, 0.45 to 1.35; P=0.37). The respective rates were 2.9% and 3.1% for stroke (P=0.79) and 3.1% and 4.1% for TIA (P=0.44). No deaths occurred by 30 days in either group, and there were no deaths from neurologic causes during the 2-year follow-up period. A cause other than paradoxical embolism was usually apparent in patients with recurrent neurologic events.. In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure with a device did not offer a greater benefit than medical therapy alone for the prevention of recurrent stroke or TIA. (Funded by NMT Medical; ClinicalTrials.gov number, NCT00201461.).

Topics: Adolescent; Adult; Anticoagulants; Aspirin; Clopidogrel; Combined Modality Therapy; Drug Therapy, Combination; Embolism, Paradoxical; Female; Foramen Ovale, Patent; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Prostheses and Implants; Secondary Prevention; Stroke; Ticlopidine; Warfarin; Young Adult

A 61-year-old man presented with transient dysarthria and left upper extremity numbness. Head MRI showed an acute infarct in the left temporal lobe and multiple old infarcts in the bilateral cortices. A transesophageal echocardiogram revealed a patent foramen ovale with a large shunt. No deep vein thrombosis was found. He suffered a recurrent cerebral infarction while taking antiplatelet therapy. An insertable cardiac monitor was implanted on the 41st day, and the antiplatelet treatment was changed to warfarin. The insertable cardiac monitor did not detect atrial fibrillation, even when the patient had a recurrent transient ischemic attack on the 57th day under warfarin therapy. The patient underwent percutaneous foramen ovale closure on the 63rd day. On postoperative days 18-25, an insertable cardiac monitor detected brief atrial fibrillation, and he took rivaroxaban for three months. Atrial fibrillation may occur secondary to percutaneous patent foramen ovale closure for cryptogenic stroke. The insertable cardiac monitor may help diagnose the pathogenesis of secondary atrial fibrillation and determine the optimal antithrombotic therapy.

Topics: Atrial Fibrillation; Fibrinolytic Agents; Foramen Ovale; Foramen Ovale, Patent; Humans; Ischemic Stroke; Male; Middle Aged; Platelet Aggregation Inhibitors; Rivaroxaban; Secondary Prevention; Stroke; Treatment Outcome; Warfarin

Topics: Aged, 80 and over; Arthroplasty; Echocardiography; Female; Foramen Ovale, Patent; Heart Ventricles; Hip; Humans; Multimodal Imaging; Pulmonary Embolism; Thrombosis; Venous Thrombosis; Warfarin

When warfarin was the mainstay of anticoagulation for the prevention of cardioembolic stroke, the paradigm was essentially "we mustn't anticoagulate anyone unless we prove that the stroke was cardioembolic." Now that direct-acting oral anticoagulants are available, the paradigm should change. The risk of stroke is highest soon after the initial event, particularly in patients with more than one infarction. Direct-acting oral anticoagulants are not significantly more likely than aspirin to cause severe hemorrhage, and it is now clear that patients with paradoxical embolism are better treated with anticoagulant than aspirin. Percutaneous closure of a patent foramen ovale is better than aspirin, but not better than anticoagulant, and some patients with paradoxical embolism may be better treated with anticoagulant than with percutaneous closure, which cannot prevent pulmonary embolism. Patients in whom cardioembolic stroke is strongly suspected should probably be anticoagulated pending the results of investigations such as echocardiography and prolonged cardiac monitoring for atrial fibrillation, and some of them, in whom the suspicion of a cardioembolic source is very strong, should probably be anticoagulated long term, even if such investigations do not confirm a cardiac source.

Topics: Anticoagulants; Aspirin; Embolism, Paradoxical; Foramen Ovale, Patent; Humans; Monitoring, Physiologic; Phenotype; Platelet Aggregation Inhibitors; Stroke; Warfarin

Topics: Anticoagulants; Coronary Artery Disease; Dyspnea; Echocardiography, Transesophageal; Embolism; Foramen Ovale, Patent; Humans; Intracranial Embolism; Magnetic Resonance Angiography; Male; Middle Aged; Multimodal Imaging; Pulmonary Embolism; Renal Artery Obstruction; Ultrasonography, Doppler; Venous Thrombosis; Warfarin

Cardioembolism is an important cause of ischemic stroke, with several studies showing worse outcome than following other stroke subtypes. Paradoxical embolism is a rare cause of cardioembolic stroke. We report a case of a patient with presumed paradoxical cardioembolic stroke secondary to thrombus formation on the eustachian valve remnant in the right atrium. The patient was anticoagulated with resolution of the mass upon follow-up assessment. The diagnostic, investigative and management strategies are discussed for patients with suspected paradoxical embolism causing stroke. Physicians are reminded of the utility of echocardiography for identifying potential cardioembolic etiologies, including both transthoracic and transesophageal echocardiography.

Topics: Anticoagulants; Echocardiography; Electrocardiography; Embolism, Paradoxical; Female; Foramen Ovale, Patent; Heart Valves; Humans; Middle Aged; Stroke; Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Female; Foramen Ovale, Patent; Heart Diseases; Humans; Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Coronary Angiography; Female; Foramen Ovale, Patent; Humans; Pacemaker, Artificial; Stroke; Thrombosis; Warfarin

Patent foramen ovale provides a passage from venous circulation to arterial circulation. This may allow passage of a thrombus formed in the venous system into the systemic circulation. We present a case in which a thrombus was entrapped in a patent foramen ovale. A 45-year-old woman presented with complaints of atypical chest pain and pretibial edema. Transthoracic echocardiography showed normal systolic function and grade I diastolic dysfunction. Pulmonary artery pressure was 43 mmHg. There was a mobile multilobular mass in the right atrium, attached to the interatrial septum via a thin pedicle. Transesophageal echocardiography showed a biatrial mass. It was 7-10 mm thick, multilobular, homogeneously echogenic, and highly mobile. It passed through the patent foramen ovale into the left atrium. The left atrial part was 6-8 mm thick, relatively shorter, and less mobile. The patient denied any symptoms related to a cerebrovascular accident. Heparin was initiated and an urgent operation was decided. Intraoperative transesophageal echocardiography showed that the mass was a thrombus which had become smaller due to anticoagulation. She had no neurologic symptoms postoperatively. Venous Doppler examination revealed deep vein thrombosis and warfarin was started.

Topics: Anticoagulants; Chest Pain; Echocardiography, Transesophageal; Female; Foramen Ovale, Patent; Heparin; Humans; Middle Aged; Treatment Outcome; Venous Thrombosis; Warfarin

Economy class stroke syndrome consists of ischemic stroke due to paradoxical embolism through patent foramen ovale after a long flight. Few cases have been described in the literature to date. The treatment choice could be tricky. We present the case of a 65-year-old woman, admitted for submassive pulmonary embolism after a long flight, that presented a paradoxical embolic stroke through patent foramen ovale shortly after. The patient was treated with intravenous thrombolysis within 1 h of stroke onset with a definite symptoms improvement. Afterwards, intravenous unfractioned heparin was started with strict partial thromboplastin time monitoring. Cerebral computed tomography scan, obtained after 24 and 72 h, ruled out hemorrhage. Warfarin was started after 72 h. Patent foramen ovale was percutaneously closed 3 months after. In the reported case, the treatment with thrombolysis and subsequent heparin infusion was effective and safe. We discuss the rationale for this treatment in the light of literature data.

Topics: Aged; Aircraft; Anticoagulants; Cardiac Surgical Procedures; Echocardiography, Transesophageal; Embolism, Paradoxical; Female; Foramen Ovale, Patent; Heparin; Humans; Pulmonary Embolism; Stroke; Thrombolytic Therapy; Time Factors; Tomography, X-Ray Computed; Travel; Treatment Outcome; Ultrasonography, Doppler, Transcranial; Warfarin

Cryptogenic stroke (or stroke of undetermined cause) is a common cause of stroke and is statistically associated with patent foramen ovale (PFO). The largest study of cryptogenic stroke is the Homma study, which is a sub-study of the WARSS trial; it produced the following data: cryptogenic stroke patients with and without PFO, when treated with either aspirin or warfarin, all had identical recurrence rates. This is puzzling because it seems as though there ought to have been some extra risk in one of the two groups under one of the two treatments. How could everything come out the same? A review of the epidemiology of cryptogenic stroke shows that, compared to patients with stroke of determined cause, cryptogenic stroke patients are a little younger and have lower doses of the usual risk factors (hypertension and diabetes mellitus) but more PFO. Cryptogenic strokes appear to be embolic strokes from an unknown source. A previously published article setting forth a hypothetical theory of stress-induced stroke was used to analyze these data. It is suggested that stress can induce episodic systemic platelet activation and hypercoagulability, which causes transient thrombus formation and subsequent embolization on both the arterial and venous sides of the circulation; the latter requires a PFO to cause a stroke (paradoxical embolism). The sum of these two mechanisms explains cryptogenic stroke. The PFO subset of cryptogenic stroke includes patients with both early and late stage disease who have an aggregate risk approximately equal to that of patients without PFO. Cryptogenic stroke is part of the disease of stress-induced cerebrovascular disease. Aspirin and warfarin have already been shown to be equally effective in secondary prevention of ischemic stroke.

Topics: Adult; Aged; Aspirin; Databases, Factual; Foramen Ovale, Patent; Humans; Middle Aged; Recurrence; Risk Factors; Stress Disorders, Traumatic; Stroke; Warfarin