Is It Closing Time? An Update on PFO & Stroke

Patent foramen ovale (PFO)—a flap-like opening between the heart’s atria—is present in about 1 in 4 adults. While typically asymptomatic, it’s implicated in roughly 5% of all strokes—and 10% of strokes in younger patients. In those ≤60 with cryptogenic stroke, PFO prevalence rises to ~50%, double that of the general population.

A July 2025 JAMA review highlights that PFO closure has shifted from a broad intervention to a more targeted therapy, with careful patient selection—guided by two key tools—at the heart of decision-making:

• RoPE score: Uses age, vascular risk factors, and infarct location to estimate whether a PFO is likely stroke-related.

• PASCAL system: Adds echocardiographic features (large shunt, atrial septal aneurysm) to classify causality as probable, possible, or unlikely.

Evidence from six randomized trials (n=3,740) shows that PFO closure reduces recurrent stroke risk (annualized rate 0.47% vs. 1.09% with medical therapy; HR 0.41). The benefit is greatest (up to 90% relative risk reduction at 2 years) in younger patients with high PASCAL scores and no vascular risk factors. Patients with low scores don’t see benefit and face higher complication risks, including atrial fibrillation.

Bottom line:

• The presence of a PFO is associated with increased risk of recurrent stroke, especially in patients with high-risk anatomical features or prior embolic events.

• PFO closure is most effective for carefully selected patients under age 60 with cryptogenic stroke, high PASCAL scores, and no major vascular risk factors.

• For patients who aren’t candidates for closure, lifelong antithrombotic therapy is recommended for secondary stroke prevention unless contraindicated. The choice between an antiplatelet and anticoagulant should be individualized based on patient risk factors and clinical context.

Reference:

Kent DM, Wang AY. JAMA. 2025;:2836861. doi:10.1001/jama.2025.10946.