How should I manage a patient with a PFO who has had a transient ischaemic attack (TIA) or stroke?

Management of a patient with a patent foramen ovale (PFO) who has experienced a transient ischaemic attack (TIA) or stroke involves a comprehensive approach focused on secondary prevention of stroke and specialist assessment.

Firstly, all patients with suspected TIA or stroke should be promptly assessed and referred for specialist evaluation within 24 hours of symptom onset to confirm diagnosis and initiate appropriate management, including consideration of underlying causes such as PFO ¹.

For secondary prevention, antiplatelet therapy such as aspirin (300 mg daily) should be started immediately unless contraindicated ¹.

Regarding PFO specifically, current UK guidelines do not provide explicit recommendations for routine closure of PFO in patients with TIA or stroke; management focuses on stroke prevention strategies including antiplatelet or anticoagulant therapy depending on individual risk factors and clinical context ¹,².

Anticoagulation may be considered if there is evidence of other embolic sources or atrial fibrillation, but aspirin remains the first-line treatment in the absence of such indications ¹,².

Decisions about PFO closure should be made in specialist settings after thorough cardiological assessment, including echocardiography, to evaluate the PFO and exclude other cardiac sources of embolism ².

Shared decision-making with the patient about risks and benefits of treatment options, including antiplatelet versus anticoagulation therapy, is essential ¹,².