Azarpazhooh, M. Reza

Bogiatzi, Chrysi

Spence, J. David

English

Scholarship@Western

Western University Scholarship@Western Department of Medicine Publications Medicine Department 3-8-2021 Shouldn't Patients With Paradoxical Emboli and Thrombophilia Be Given Anticoagulant Agents? M. Reza Azarpazhooh Chrysi Bogiatzi J. David Spence jdspence@uwo.ca Follow this and additional works at: https://ir.lib.uwo.ca/medpub Citation of this paper: Azarpazhooh, M. Reza; Bogiatzi, Chrysi; and Spence, J. David, "Shouldn't Patients With Paradoxical Emboli and Thrombophilia Be Given Anticoagulant Agents?" (2021). Department of Medicine Publications. 164. https://ir.lib.uwo.ca/medpub/164 LettersTO THE EDITORShouldn’t Patients WithParadoxical Emboli andThrombophilia Be GivenAnticoagulant Agents?Liu et al. (1) reported that patients with thrombophiliaand a stroke or transient ischemic attack attributed topatent foramen ovale (PFO) benefited from closure ofthe PFO. Among the 46 patients with thrombophiliawho received medical therapy only, the recurrencerates were 22.6% with warfarin versus 53.3% withantiplatelet therapy (p ¼ 0.041 by Fisher exact test).The investigators commented that anticoagulantagents were not shown to be beneficial in patientswith embolic stroke of unknown source. It is verylikely that misclassification of large-artery strokes asembolic strokes of unknown source accounted forthat finding: defining large-artery atherosclerosis by a50% stenosis misses 79% of large-artery strokes clas-sified by a high carotid plaque burden (2).A meta-analysis of anticoagulant versus antiplate-let therapy in patients with PFO reported significantbenefit of anticoagulation (3). In another meta-analysis, anticoagulation was equivalent to PFOclosure (4).A paradoxical embolus is essentially a pulmonaryembolus that turned left to traverse a PFO instead ofturning right into the pulmonary artery. Closure of thePFO can prevent a stroke, but not a pulmonaryembolus.In the past, we were very reluctant to treat patientswith warfarin; the paradigm was that we would notgive patients anticoagulant agents without a provencardioembolic source (typically atrial fibrillation).Now that we have anticoagulant agents that arenot significantly more likely than antiplatelet agentsto cause severe hemorrhage (5), the paradigmshould change. Shouldn’t all patients withparadoxical embolism and a thrombophilia be givenanticoagulation long term?M. Reza Azarpazhooh, MDChrysi Bogiatzi, MSc, MD*J. David Spence, MD*Stroke Prevention & Atherosclerosis Research CentreRobarts Research InstituteWestern University1400 Western RoadLondon, ON, N6G 2V4CanadaE-mail: dspence@robarts.cahttp://dx.doi.org/10.1016/j.jcin.2020.12.024 2021 by the American College of Cardiology Foundation. Published by Elsevier.The authors have reported that they have no relationships relevant to thecontents of this paper to disclose.The authors attest they are in compliance with human studies committees andanimal welfare regulations of the authors’ institutions and Food and DrugAdministration guidelines, including patient consent where appropriate. Formore information, visit the Author Center.RE F E RENCE S1. Liu K, Song B, Palacios IF, et al. Patent foramen ovale attributable cryp-togenic embolism with thrombophilia has higher risk for recurrence and re-sponds to closure. J Am Coll Cardiol Intv 2020;13:2745–52.2. Bogiatzi C, Wannarong T, McLeod AI, Heisel M, Hackam D, Spence JD.SPARKLE (Subtypes of Ischaemic Stroke Classification System), incorpo-rating measurement of carotid plaque burden: a new validated tool for theclassification of ischemic stroke subtypes. Neuroepidemiology 2014;42:243–51.3. Kasner SE, Swaminathan B, Lavados P, et al. Rivaroxaban or aspirin forpatent foramen ovale and embolic stroke of undetermined source: a pre-specified subgroup analysis from the NAVIGATE ESUS trial. Lancet Neurol2018;17:1053–60.4. Saber H, Palla M, Kazemlou S, Azarpazhooh MR, Seraji-Bozorgzad N,Behrouz R. Network meta-analysis of patent foramen ovale managementstrategies in cryptogenic stroke. Neurology 2018;91:e1–7.5. Connolly SJ, Eikelboom J, Joyner C, et al. Apixaban in patients with atrialfibrillation. N Engl J Med 2011;364:806–17.REPLY: Shouldn’t Patients WithParadoxical Emboli and Thrombophilia BeGiven Anticoagulant Agents?We deeply appreciate Drs. Azarpazhooh, Bogiatzi,and Spence’s interest and insight into our recentpublication reporting increased risk of recurrence inpatent foramen ovale (PFO) stroke patients withthrombophilia (1). We wholeheartedly agree withtheir astute comment about the important role ofanticoagulation (AC) in patients with thrombophilia,not just to prevent stroke, but also pulmonaryembolisms. The challenge remains that thrombo-philias are heterogeneous and opportunistic, andJ A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S VO L . 1 4 , N O . 5 , 2 0 2 1I S S N 1 9 3 6 - 8 7 9 8 / $ 3 6 . 0 0

Shouldn\u27t Patients With Paradoxical Emboli and Thrombophilia Be Given Anticoagulant Agents?

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Shouldn\u27t Patients With Paradoxical Emboli and Thrombophilia Be Given Anticoagulant Agents?

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