title: Closure of patent foramen ovale versus medical therapy after cryptogenic stroke.
abstract: BACKGROUND
  Whether closure of a patent foramen ovale is effective in the prevention of recurrent ischemic stroke in patients who have had a cryptogenic stroke is unknown. We conducted a trial to evaluate whether closure is superior to medical therapy alone in preventing recurrent ischemic stroke or early death in patients 18 to 60 years of age.
  
  
  METHODS
  In this prospective, multicenter, randomized, event-driven trial, we randomly assigned patients, in a 1:1 ratio, to medical therapy alone or closure of the patent foramen ovale. The primary results of the trial were analyzed when the target of 25 primary end-point events had been observed and adjudicated.
  
  
  RESULTS
  We enrolled 980 patients (mean age, 45.9 years) at 69 sites. The medical-therapy group received one or more antiplatelet medications (74.8%) or warfarin (25.2%). Treatment exposure between the two groups was unequal (1375 patient-years in the closure group vs. 1184 patient-years in the medical-therapy group, P=0.009) owing to a higher dropout rate in the medical-therapy group. In the intention-to-treat cohort, 9 patients in the closure group and 16 in the medical-therapy group had a recurrence of stroke (hazard ratio with closure, 0.49; 95% confidence interval [CI], 0.22 to 1.11; P=0.08). The between-group difference in the rate of recurrent stroke was significant in the prespecified per-protocol cohort (6 events in the closure group vs. 14 events in the medical-therapy group; hazard ratio, 0.37; 95% CI, 0.14 to 0.96; P=0.03) and in the as-treated cohort (5 events vs. 16 events; hazard ratio, 0.27; 95% CI, 0.10 to 0.75; P=0.007). Serious adverse events occurred in 23.0% of the patients in the closure group and in 21.6% in the medical-therapy group (P=0.65). Procedure-related or device-related serious adverse events occurred in 21 of 499 patients in the closure group (4.2%), but the rate of atrial fibrillation or device thrombus was not increased.
  
  
  CONCLUSIONS
  In the primary intention-to-treat analysis, there was no significant benefit associated with closure of a patent foramen ovale in adults who had had a cryptogenic ischemic stroke. However, closure was superior to medical therapy alone in the prespecified per-protocol and as-treated analyses, with a low rate of associated risks. (Funded by St. Jude Medical; RESPECT ClinicalTrials.gov number, NCT00465270.).
authors.affiliation: University of Colorado Denver/University of Colorado Hospital, Aurora, CO 80045, USA. john.carroll@ucdenver.edu
authors.forename: John D
authors.initials: JD
authors.lastname: Carroll
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Saver
authors.forename: David E
authors.initials: DE
authors.lastname: Thaler
authors.forename: Richard W
authors.initials: RW
authors.lastname: Smalling
authors.forename: Scott
authors.initials: S
authors.lastname: Berry
authors.forename: Lee A
authors.initials: LA
authors.lastname: MacDonald
authors.forename: David S
authors.initials: DS
authors.lastname: Marks
authors.forename: David L
authors.initials: DL
authors.lastname: Tirschwell
mesh_terms: D000328:Adult; D006328:Cardiac Catheterization / Q000009:adverse effects; D004617:Embolism / Q000209:etiology / Q000517:prevention & control; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D005500:Follow-Up Studies; D054092:Foramen Ovale, Patent / Q000150:complications / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012306:Risk; D055502:Secondary Prevention; D055989:Septal Occluder Device / Q000009:adverse effects; D016037:Single-Blind Method; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents