CLINICAL RESEARCH: PATENT FORAMEN AND STROKE
Patent Foramen Ovale and the Risk of Ischemic Stroke in a Multiethnic Population
Marco R. Di Tullio, MD*,1,*,
Ralph L. Sacco, MD , ,
Robert R. Sciacca, EngScD*,
Zhezhen Jin, PhD and
Shunichi Homma, MD, FACC*,2
* Department of Medicine, Columbia University Medical Center, New York, New York
Department of Neurology, Columbia University Medical Center, New York, New York
Department of Epidemiology and Public Health at the Sergievsky Center, Columbia University Medical Center, New York, New York
Department of Biostatistics, Columbia University Medical Center, New York, New York.
Manuscript received June 27, 2006;
revised manuscript received August 11, 2006,
accepted August 14, 2006.
* Reprint requests and correspondence: Dr. Marco R. Di Tullio, Professor of Clinical Medicine, Columbia University Medical Center, PH3-342, 622 West 168th Street, New York, New York 10032. (Email: md42{at}columbia.edu).
This study was presented in part at the 2003 American Heart Association Stroke International Conference, Phoenix, Arizona.
OBJECTIVES: We sought to assess the risk of ischemic stroke from a patent foramen ovale (PFO) in the multiethnic prospective cohort of northern Manhattan.
BACKGROUND: Patent foramen ovale has been associated with increased risk of ischemic stroke, mainly in case-control studies. The actual PFO-related stroke risk in the general population is unclear.
METHODS: The presence of PFO was assessed at baseline by using transthoracic 2-dimensional echocardiography with contrast injection in 1,100 stroke-free subjects older than 39 years of age (mean age 68.7 ± 10.0 years) from the Northern Manhattan Study (NOMAS). The presence of atrial septal aneurysm (ASA) also was recorded. Subjects were followed annually for outcomes. We assessed PFO/ASA-related stroke risk after adjusting for established stroke risk factors.
RESULTS: We detected PFO in 164 subjects (14.9%); ASA was present in 27 subjects (2.5%) and associated with PFO in 19 subjects. During a mean follow-up of 79.7 ± 28.0 months, an ischemic stroke occurred in 68 subjects (6.2%). After adjustment for demographics and risk factors, PFO was not found to be significantly associated with stroke (hazard ratio 1.64, 95% confidence interval [CI] 0.87 to 3.09). The same trend was observed in all age, gender, and race-ethnic subgroups. The coexistence of PFO and ASA did not increase the stroke risk (adjusted hazard ratio 1.25, 95% CI 0.17 to 9.24). Isolated ASA was associated with elevated stroke incidence (2 of 8, or 25%; adjusted hazard ratio 3.66, 95% CI 0.88 to 15.30).
CONCLUSIONS: Patent foramen ovale, alone or together with ASA, was not associated with an increased stroke risk in this multiethnic cohort. The independent role of ASA needs further assessment in appositely designed and powered studies.
|
Abbreviations and Acronyms
| | ASA = atrial septal aneurysm | | CI = confidence interval | | PFO = patent foramen ovale | | TEE = transesophageal echocardiography |
|
This article has been cited by other articles:
|
|
|
|
 
S. Buchholz, A. Shakil, G. A. Figtree, P. S. Hansen, and R. Bhindi
Diagnosis and management of patent foramen ovale
Postgrad. Med. J.,
January 25, 2012;
(2012)
postgradmedj-2011-130368v.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
A. Pezzini, M. Grassi, C. Lodigiani, R. Patella, C. Gandolfo, A. Zini, R. Musolino, R. S. Calabro, P. Bovi, A. Adami, et al.
Interaction between proatherosclerotic factors and right-to-left shunt on the risk of cryptogenic stroke: the Italian Project on Stroke in Young Adults
Heart,
January 23, 2012;
(2012)
heartjnl-2011-300970v1.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
A. M. Forteza, S. Koch, I. Campo-Bustillo, J. Gutierrez, D. C. Haussen, A. A. Rabinstein, J. Romano, G. A. Zych, and R. Duncan
Transcranial Doppler Detection of Cerebral Fat Emboli and Relation to Paradoxical Embolism: A Pilot Study
Circulation,
May 10, 2011;
123(18):
1947 - 1952.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Perry, D. C. Shook, F. Nhuch, H. Chou, S. Shernan, and W. L. Gross
Repairing Interatrial Septal Defects From the Operating Room to the Cardiac Catheterization Laboratory: 2D or Not 2D?
Seminars in Cardiothoracic and Vascular Anesthesia,
March 1, 2011;
15(1-2):
8 - 13.
[Abstract]
[PDF]
|
|
|
|
|
|
|
L. B. Goldstein, C. D. Bushnell, R. J. Adams, L. J. Appel, L. T. Braun, S. Chaturvedi, M. A. Creager, A. Culebras, R. H. Eckel, R. G. Hart, et al.
Guidelines for the Primary Prevention of Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Stroke,
February 1, 2011;
42(2):
517 - 584.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. O. Na, S. Y. Shin, H. E. Lim, C. U. Choi, S. H. Kim, J. W. Kim, E. J. Kim, E. M. Lee, S.-W. Rha, C. G. Park, et al.
Impaired transport function of the left atrium and left atrial appendage in cryptogenic stroke patients with atrial septal aneurysm and without patent foramen ovale
Eur Heart J Cardiovasc Imaging,
February 1, 2011;
12(2):
140 - 147.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. L. Furie, S. E. Kasner, R. J. Adams, G. W. Albers, R. L. Bush, S. C. Fagan, J. L. Halperin, S. C. Johnston, I. Katzan, W. N. Kernan, et al.
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Stroke,
January 1, 2011;
42(1):
227 - 276.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Tugcu, K. Okajima, Z. Jin, T. Rundek, S. Homma, R. L. Sacco, M. S. V. Elkind, and M. R. Di Tullio
Septal Pouch in the Left Atrium and Risk of Ischemic Stroke
J. Am. Coll. Cardiol. Img.,
December 1, 2010;
3(12):
1276 - 1283.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. A. Tighe and G. P. Aurigemma
Right-to-Left Shunts and Saline Contrast Echocardiography
Chest,
August 1, 2010;
138(2):
246 - 248.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Chandrashekhar
PFO and the Heart: More Than Meets the Eye!
J. Am. Coll. Cardiol. Img.,
August 1, 2010;
3(8):
840 - 842.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Pepi, A. Evangelista, P. Nihoyannopoulos, F. A. Flachskampf, G. Athanassopoulos, P. Colonna, G. Habib, E. B. Ringelstein, R. Sicari, J. L. Zamorano, et al.
Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC)
Eur Heart J Cardiovasc Imaging,
July 1, 2010;
11(6):
461 - 476.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Garg, S. J. Servoss, J. C. Wu, Z. H. Bajwa, M. H. Selim, A. Dineen, R. E. Kuntz, E. F. Cook, and L. Mauri
Lack of Association Between Migraine Headache and Patent Foramen Ovale: Results of a Case-Control Study
Circulation,
March 30, 2010;
121(12):
1406 - 1412.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. A. Krasuski, S. A. Hart, D. Allen, A. Qureshi, G. Pettersson, P. L. Houghtaling, L. H. Batizy, and E. Blackstone
Prevalence and Repair of Intraoperatively Diagnosed Patent Foramen Ovale and Association With Perioperative Outcomes and Long-term Survival
JAMA,
July 15, 2009;
302(3):
290 - 297.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Rajamani, S. Chaturvedi, Z. Jin, S. Homma, R. L. Brey, B. C. Tilley, R. L. Sacco, J.L.P. Thompson, J.P. Mohr, S. R. Levine, et al.
Patent Foramen Ovale, Cardiac Valve Thickening, and Antiphospholipid Antibodies as Risk Factors for Subsequent Vascular Events: The PICSS-APASS Study
Stroke,
July 1, 2009;
40(7):
2337 - 2342.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H.-C. Diener and C. Weimar
Update of secondary stroke prevention
Nephrol. Dial. Transplant.,
June 1, 2009;
24(6):
1718 - 1724.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. T. O'Gara, S. R. Messe, E. M. Tuzcu, G. Catha, and J. C. Ring
Percutaneous Device Closure of Patent Foramen Ovale for Secondary Stroke Prevention: A Call for Completion of Randomized Clinical Trials A Science Advisory From the American Heart Association/American Stroke Association and the American College of Cardiology Foundation The American Academy of Neurology affirms the value of this science advisory
J. Am. Coll. Cardiol.,
May 26, 2009;
53(21):
2014 - 2018.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. T. O'Gara, S. R. Messe, E. M. Tuzcu, G. Catha, and J. C. Ring
Percutaneous Device Closure of Patent Foramen Ovale for Secondary Stroke Prevention: A Call for Completion of Randomized Clinical Trials: A Science Advisory From the American Heart Association/American Stroke Association and the American College of Cardiology Foundation The American Academy of Neurology affirms the value of this science advisory.
Circulation,
May 26, 2009;
119(20):
2743 - 2747.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. Meier
Stroke and migraine: a cardiologist's headache
Heart,
April 1, 2009;
95(7):
595 - 602.
[Full Text]
[PDF]
|
|
|
|
|
|
|
H.-C. Diener, H. Mattle, M. Bohm, and F. Ruschitzka
CHAPTER 15a The Heart and the Brain
ESC Textbook of Cardiovascular Medicine,
January 1, 2009;
2(1):
med-9780199566990-chapter - med-9780199566990-chapter.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
S. R. Messe and S. E. Kasner
Patent Foramen Ovale in Cryptogenic Stroke: Not to Close
Circulation,
November 4, 2008;
118(19):
1999 - 2004.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Rundek, M. S.V. Elkind, M. R. Di Tullio, E. Carrera, Z. Jin, R. L. Sacco, and S. Homma
Patent Foramen Ovale and Migraine: A Cross-Sectional Study From the Northern Manhattan Study (NOMAS)
Circulation,
September 30, 2008;
118(14):
1419 - 1424.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. R. Opotowsky, M. J. Landzberg, and G. D. Webb
Percutaneous Closure of Patent Foramen Ovale and Atrial Septal Defect--Reply
JAMA,
May 21, 2008;
299(19):
2272 - 2273.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. E. Weyman
The Year in Echocardiography
J. Am. Coll. Cardiol.,
March 25, 2008;
51(12):
1221 - 1229.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Doufekias, A. Z. Segal, and J. R. Kizer
Cardiogenic and Aortogenic Brain Embolism
J. Am. Coll. Cardiol.,
March 18, 2008;
51(11):
1049 - 1059.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. L. P. Slottow, D. H. Steinberg, and R. Waksman
Overview of the 2007 Food and Drug Administration Circulatory System Devices Panel Meeting on Patent Foramen Ovale Closure Devices
Circulation,
August 7, 2007;
116(6):
677 - 682.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. R. Di Tullio, R. L. Sacco, R. R. Sciacca, Z. Jin, and S. Homma
Reply
J. Am. Coll. Cardiol.,
July 3, 2007;
50(1):
81 - 81.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Schwerzmann and B. Meier
Patent Foramen Ovale and Stroke Risk: The Devil Is in the Detail
J. Am. Coll. Cardiol.,
July 3, 2007;
50(1):
80 - 80.
[Full Text]
[PDF]
|
|
|
|
