Predictors of recurrent events in patients with cryptogenic stroke and patent foramen ovale within the CLOSURE I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack Due to Presumed Paradoxical Embolism Through a Patent Foramen Ovale) trial.

Abstract

OBJECTIVES:

This study sought to identify predictors of recurrent ischemic neurologic events within the CLOSURE I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack Due to Presumed Paradoxical Embolism Through a Patent Foramen Ovale) trial.

BACKGROUND:

The CLOSURE I trial found that transcatheter patent foramen ovale (PFO) closure using the STARFlex device was not superior to medical therapy in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO.

METHODS:

The CLOSURE I trial is a multicenter, randomized trial of transcatheter PFO closure compared with medical therapy in patients who presented with cryptogenic stroke or TIA and had a PFO. We identified clinical predictors of recurrent ischemic stroke or TIA during 2 years of follow-up using Cox proportional hazards regression within the pooled intention-to-treat cohort.

RESULTS:

In 909 patients, the incidence of recurrent events was 5.7% with 25 patients suffering a recurrent stroke and 30 a TIA. Patients who had a recurrent event had higher body mass index (30.2 ± 6.2 vs. 28.3 ± 5.8%; p = 0.03) and more frequently had diabetes (19.2% vs. 7.1%; p = 0.0016), hypertension (46.2% vs. 30.1%; p = 0.015), and ischemic heart disease (3.8% vs. 0.9%; p = 0.05). Diabetes (hazard ratio [HR]: 3.39; 95% confidence interval [CI]: 1.69 to 6.84; p = 0.0007), index TIA (HR vs. stroke: 2.13; 95% CI: 1.20 to 3.80; p = 0.01), and the detection of atrial fibrillation after study enrollment (HR: 4.85; 95% CI: 2.05 to 11.47; p = 0.0003) independently predicted recurrent ischemic neurologic events. Recurrent neurologic events were more frequent in subjects with RoPE (Risk of Paradoxical Embolism) score ≤5 than those with >5 (14.5% vs. 4.2%; p < 0.0001).

CONCLUSIONS:

These findings suggest an alternative etiology to paradoxical embolism was frequently responsible for recurrent events within the CLOSURE I trial. (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke or TIA Due to the Possible Passage of a Clot of Unknown Origin Through a Patent Foramen Ovale (PFO) [CLOSURE I]; NCT00201461).

• Authors: Sammy Elmariah, Anthony J Furlan, Mark Reisman, David Burke, Moshe Vardi, Neil J Wimmer, Shuqiong Ling, Xiaohua Chen, David M Kent, Joseph Massaro, Laura Mauri, CLOSURE I Investigators
• Journal: JACC. Cardiovascular interventions (JACC Cardiovasc Interv) Vol. 7 Issue 8 Pg. 913-20 (Aug 2014) ISSN: 1876-7605 [Electronic] United States
• PMID: 25147037 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Topics

• Adult
• Cardiac Catheterization (adverse effects, instrumentation)
• Chi-Square Distribution
• Comorbidity
• Embolism, Paradoxical (diagnosis, etiology, prevention & control)
• Female
• Foramen Ovale, Patent (complications, diagnosis, therapy)
• Humans
• Intention to Treat Analysis
• Ischemic Attack, Transient (diagnosis, etiology, prevention & control)
• Male
• Middle Aged
• Multivariate Analysis
• Proportional Hazards Models
• Prospective Studies
• Prosthesis Design
• Recurrence
• Risk Factors
• Secondary Prevention (instrumentation, methods)
• Septal Occluder Device
• Stroke (diagnosis, etiology, prevention & control)
• Time Factors
• Treatment Outcome
• United States