Clinicians' Approach to Patent Foramen Ovale Closure after Stroke: Comparing Cardiologists and Neurologists

Abstract

Background Evidence from randomized trials and updated professional society guidelines supports patent foramen ovale (PFO) closure after cryptogenic stroke in select patients. It is unclear how this has been integrated into real‐world practice, so we aimed to compare practice patterns between cardiologists and neurologists. Methods and Results In March of 2021, a survey of cardiologists and neurologists who work or previously trained at the University of Pennsylvania Health System assessed practice preferences with respect to PFO closure after stroke. Clinical vignettes isolated specific variables of interest and used a 5‐point Likert scale to assess the level of support for PFO closure. Stroke neurologists and interventional cardiologists were compared by Wilcoxon‐Mann–Whitney tests. Secondarily, Kruskal–Wallis tests compared stroke neurologists, general neurologists, interventional cardiologists, and general cardiologists. We received 106 responses from 182 survey recipients (31/31 stroke neurologists, 38/46 interventional cardiologists, 20/30 general neurologists, and 17/77 general cardiologists). A similar proportion of stroke neurologists and interventional cardiologists favored PFO closure in a young patient with cryptogenic stroke, 88% and 87%, respectively ( P =0.54). Interventionalists were more likely than stroke neurologists to support closure in the context of an alternative high‐risk stroke mechanism, 14% and 0%, respectively ( P =0.003). Stroke neurologists were more likely to oppose closure on the basis of older age ( P =0.01). Conclusions There are key differences between how neurologists and cardiologists approach PFO closure after stroke, particularly when interpreting the stroke etiology and when considering closure beyond the scope of prior trials; this underscores the importance of collaboration between cardiologists and neurologists.

Management of Patients With Patent Foramen Ovale and Stroke: A National Survey of Interventional Cardiologists and Vascular Neurologists

“…Interventional cardiologists are consistently more supportive of PFO closure than stroke neurologists. A similar pattern was reported in a recent single‐center study, 10 but here we report a large national sample that is more broadly representative of clinical practice in the United States. The discrepancy between cardiologists and neurologists was similarly evident in a 2005 multicenter survey that long preceded the landmark trials.…”

“…In the prior survey from a single center, there was less support for closure among general neurologists and general cardiologists, but stroke neurologists and interventional cardiologists were equally supportive of closure in the case of a carefully selected patient. 10 However, those results likely reflected local practice within a large health system with a long history of PFO‐related collaboration, whereas the current report is more indicative of broader practice patterns and better powered to reveal differences between subspecialists.…”

“…In keeping with the overall trend, stroke neurologists are more likely to recommend against closure based on advanced age, as was reported from a prior single‐center survey. 10 Thirty‐nine percent of interventionists would consider PFO closure at any age, compared with only 15% of neurologists. CLOSE (PFO Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence), REDUCE (GORE Septal Occluder Device for PFO Closure in Stroke Patients), and RESPECT (Patent Foramen Closure or Medical Therapy after Stroke) excluded patients beyond the age of 60 years, 1 , 2 , 3 but there was no evidence of reduced benefit in older patients in these trials and DEFENSE‐PFO did not restrict enrollment based on age.…”

“…Our group recently reported that within a single academic health care system, interventional cardiologists and stroke neurologists are similarly supportive of PFO closure in very well selected young patients with cryptogenic stroke, but there was practice variability when considering alternative stroke mechanisms, patient age, and other factors that were beyond the scope of prior trials. 10 Given the limited generalizability of a single‐center study, here we aimed to quantify practice patterns in a national sample of stroke neurologists and interventional cardiologists to test the hypothesis that stroke neurologists tend to be less aggressive than interventional cardiologists in recommending PFO closure after stroke.…”

Patent Foramen Ovale Management for Secondary Stroke Prevention: State-of-the-Art Appraisal of Current Evidence

“…Importantly, neurologists and cardiologists have dissimilar interpretations of stroke etiologies when making decisions beyond the scope of clinical trials. 57 Therefore, neurocardiology interactions may lead to improved communications and a more homogeneous approach during the decision-making process. Despite this rationale and the specific FDA recommendations, the impact of neurocardiology teams on adherence to international recommendations and clinical outcomes has not been assessed.…”