Comparable benefits and harms of anticoagulant and antiplatelet treatment in patients with PFO and cryptogenic stroke

Reference

Sagris D, Georgiopoulos G, Perlepe K, et al. Antithrombotic treatment in cryptogenic stroke patients with patent foramen ovale: systematic review and meta-analysis. Stroke 2019;50(11):3135-3140.

Synopsis

These authors searched PubMed for randomized trials that evaluated "antithrombotic, anticoagulant or antiplatelet" medications in the prevention of subsequent stroke in patients with cryptogenic stroke and PFO. They also manually searched references of included studies, editorials, reviews, letters, and so forth, and contacted experts in the field to identify other studies. Curiously, they didn't search clinical trials registries or other databases. Two authors evaluated studies for inclusion and assessed the risk of bias for each included study. They resolved disagreements by consensus. Although the paper does not state whether this study was supported by any external funding, several of the authors have financial ties to industry. Ultimately, they included 5 trials with 1720 patients. Overall, the studies were of moderate quality. The anticoagulants were slightly more effective than antiplatelet agents in preventing subsequent strokes, but the differences were not statistically significant. Similarly, although the antiplatelet agents caused less major bleeding than the anticoagulants, the differences were not statistically significant. Parenthetically, one of the trials did not report major bleeding. In the 4 trials that reported benefits and harms, antiplatelet agents and anticoagulants were similar for every stroke prevented there was approximately one major bleed. We have previously covered studies that raised uncertainty about the risk of subsequent stroke in patients with PFO and suggest that PFO closure is more effective than medical treatment at preventing subsequent stroke (at the risk of developing atrial fibrillation).