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New recommendation offered for younger stroke patients

Monday 30th July 2018
An evaluation of three medical studies has led to a new recommendation on the best way to prevent strokes among patients aged under 60.
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Patients aged below 60 who have suffered ischemic strokes in the past are less likely to have a recurrence if they are treated with a combination of patent foramen ovale (PFO) closure plus antiplatelet therapy, an expert panel has advised. 

The panel was established in a collaboration between British Medical Journal and the MAGIC (Making GRADE the Irresistible Choice) project, whose members are mostly based in Norway and Canada.

Between them, the panel members carried out a systematic review of the available literature on the subject and concluded that the combination of PFO closure and antiplatelets was likely to be more effective in preventing ischemic stroke recurrence than indefinite anticoagulant therapy.

It said this was the better option because "the most serious complications of PFO closure are usually short term, whereas anticoagulation imposes a long-term burden and increased risk of major bleeding".

The conclusion was based on a trio of multicentre studies examined by the panel that were all published in September last year. However, the panel acknowledged that there are caveats to their recommendation; in particular, the studies did not offer conclusive data on all the respective risks and benefits of the options. 

Consequently, based on the GRADE classification system, the PFO/antiplatelet combination recommendation is listed as 'weak,' although this changes to 'strong' if anticoagulation therapy is either declined as a treatment option or clearly established in any particular medical case not to be the best option. 

Explaining this distinction, guideline panel chair Dr Frederick Spencer from McMaster University in Hamilton, Ontario explained that a 'weak' recommendation "should recognise that different choices will be appropriate for different patients".

For those who are unwilling to undergo PFO closure, the panel also issued a "weak recommendation" for anticoagulation therapy over antiplatelet therapy.  

System chairman for cardiology at the Ochsner Medical Center in New Orleans Dr Christopher White said that when it is explained to patients that PFO is "a one-and-done procedure” they tend to opt for this treatment, rather than being continuously on anticoagulation therapy for decades.

Written by Matthew Horton

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