Patent foramen ovale diagnosis in young stroke patients: analysis of recurrence and mortality

Abstract

Background: Revised European Stroke Organization guidelines in 2018 recommend early patent foramen ovale (PFO) detection and closure in patients aged 60 or younger who suffered an ischemic stroke. Our primary aim was to analyze the impact of these guidelines on the detection of PFO. Our secondary endpoints were to investigate the differences in the risk of recurrence and mortality among PFO status.

Methods: We conducted a population-based, retrospective cohort study in Catalonia using linked health administration databases. We included all ischemic stroke patients aged 18-60 from 2016 to 2021, collecting PFO diagnosis, demographics, comorbidities, stroke recurrence, and mortality.

Results: A total of 13,780 individuals suffered an ischemic stroke, representing a raw annual incidence rate of 30.3 cases-per-100,000 inhabitants/year. PFO was detected in 749(5.4%), and these were younger, and had a lower prevalence of risk factors than patients without PFO (all p value < 0.05). After adjusting for age and sex, PFO diagnoses increased by 59% following the guidelines update. Five-year recurrence was 12.1% [95%CI 11.3-12.9] with no differences by age and PFO. Socioeconomical status and diabetes emerged as predictors of recurrence. Stroke patients with PFO showed a lower mortality rate (p value = 0.016). However, when stratified by age, PFO was linked to lower 4-year mortality only in patients ≤ 50 years.

Conclusions: We confirm a greater detection of PFO in real-world practice following the update of guidelines. Regarding the risk of recurrence, socioeconomic status and diabetes were the only independent predictors of new stroke events. Additionally, we found a lower all-cause mortality in younger patients with PFO.

Keywords: Guidelines; Incidence; Ischemic stroke; Mortality; Patent foramen ovale; Recurrence.

Fig. 1

Incidence of stroke at younger ages. Panel A depicts the raw incidence rates per 100,000 inhabitants by age (individuals older and younger than 50). Panel B stratifies the incidence rates by decades of life

Fig. 2

Change in the trend of PFO diagnosis within time. Panel A displays de increase in PFO diagnosis within the full study period. Panel B compares this increase in the periods before (2016–2017, blue) and after (2019–2021, orange) the update in clinical guidelines. We additionally show how this trend differs according to age of participants (panel C) and sex (panel D)

Fig. 3

All-cause mortality in the cohort by presence of PFO. Panel A compares the causes of death between those patients with and without PFO. Panel B depicts the survival function in the sample by age (older or younger than 50) and by presence of PFO. Risk depicts the number of patients at risk and the cumulative number of events by groups