title: Recurrent stroke predictors differ in medically treated patients with pathogenic vs. other PFOs.
abstract: OBJECTIVE
  To examine predictors of stroke recurrence in patients with a high vs a low likelihood of having an incidental patent foramen ovale (PFO) as defined by the Risk of Paradoxical Embolism (RoPE) score.
  
  
  METHODS
  Patients in the RoPE database with cryptogenic stroke (CS) and PFO were classified as having a probable PFO-related stroke (RoPE score of >6, n = 647) and others (RoPE score of ≤6 points, n = 677). We tested 15 clinical, 5 radiologic, and 3 echocardiographic variables for associations with stroke recurrence using Cox survival models with component database as a stratification factor. An interaction with RoPE score was checked for the variables that were significant.
  
  
  RESULTS
  Follow-up was available for 92%, 79%, and 57% at 1, 2, and 3 years. Overall, a higher recurrence risk was associated with an index TIA. For all other predictors, effects were significantly different in the 2 RoPE score categories. For the low RoPE score group, but not the high RoPE score group, older age and antiplatelet (vs warfarin) treatment predicted recurrence. Conversely, echocardiographic features (septal hypermobility and a small shunt) and a prior (clinical) stroke/TIA were significant predictors in the high but not low RoPE score group.
  
  
  CONCLUSIONS
  Predictors of recurrence differ when PFO relatedness is classified by the RoPE score, suggesting that patients with CS and PFO form a heterogeneous group with different stroke mechanisms. Echocardiographic features were only associated with recurrence in the high RoPE score group.
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland. dthaler@tuftsmedicalcenter.org.
authors.forename: David E
authors.initials: DE
authors.lastname: Thaler
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Robin
authors.initials: R
authors.lastname: Ruthazer
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Christian
authors.initials: C
authors.lastname: Weimar
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Mas
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Joaquín
authors.initials: J
authors.lastname: Serena
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Di Angelantonio
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Federica
authors.initials: F
authors.lastname: Papetti
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Shunichi
authors.initials: S
authors.lastname: Homma
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Heinrich P
authors.initials: HP
authors.lastname: Mattle
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Krassen
authors.initials: K
authors.lastname: Nedeltchev
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Marie-Luise
authors.initials: ML
authors.lastname: Mono
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Jaigobin
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Patrik
authors.initials: P
authors.lastname: Michel
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Mitchell S V
authors.initials: MS
authors.lastname: Elkind
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Marco R
authors.initials: MR
authors.lastname: Di Tullio
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Lutz
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: John
authors.initials: J
authors.lastname: Griffith
authors.affiliation: From the Department of Neurology (D.E.T., D.M.K.) and the Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies (R.R., J.S.L., J.G., D.M.K.), Tufts Medical Center/Tufts University School of Medicine, Boston, MA; the University of Duisburg-Essen (C.W.), Germany; Hôpital Sainte-Anne (J.L.-M.), Paris-Descartes University, France; the Department of Neurology (J.S.), Hospital Universitari Doctor Josep Trueta Institut d'Investigació Biomèdica de Girona, Spain; the Department of Public Health and Primary Care (E.D.A.), Cambridge University, UK; the Department of Cardiology (F.P.), Sapienza University of Rome, Italy; the Departments of Cardiology (S.H.) and Neurology and Epidemiology (M.S.V.E.) and the Division of Cardiology (M.R.D.T.), Columbia University, New York; Inselspital (H.P.M., M.-L.M.), University of Bern; the Division of Neurology (K.N.), Triemli Municipal Hospital, Zurich, Switzerland; the University of Toronto (C.J.), Canada; and Centre Hospitalier Universitaire Vaudois (P.M.), Switzerland.
authors.forename: David M
authors.initials: DM
authors.lastname: Kent
mesh_terms: D000328:Adult; D000368:Aged; D015897:Comorbidity; D016208:Databases, Factual; D019320:Embolism, Paradoxical / Q000453:epidemiology*; D005260:Female; D005500:Follow-Up Studies; D054092:Foramen Ovale, Patent / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology*; D006801:Humans; D002546:Ischemic Attack, Transient / Q000188:drug therapy / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012008:Recurrence; D018570:Risk Assessment; D020521:Stroke / Q000188:drug therapy / Q000453:epidemiology*