ADD-ONS / SCALES AND SCORES

ROPE score

(Risk of Paradoxical Embolism)

Created 09/12/2021, last revision 08/09/2022

  • the prevalence of PFO in the general population is approximately 25%; in the cryptogenic stroke (CS) population, PFO is overrepresented (prevalence of approx. 50%)
  • the discovery of a PFO in an individual patient with an otherwise occult etiology is not synonymous with a diagnosis of paradoxical embolism
  • the RoPE score was proposed to help establish the relation between cryptogenic stroke and PFO
  • a validation suggests that the RoPE score identifies cryptogenic stroke patients who are likely to have a pathogenic PFO
    • the relationship between the RoPE score and the effect of PFO closure was evaluated in 3 randomized trials (Kent, 2020)
    • in the low RoPE score group (<7), the rate of recurrent strokes per 100 person-years was 1.37 in the device arm versus 1.68 in the medical arm (hazard ratio, 0.82 [0.42-1.59] P=0.56) compared with 0.30 versus 1.03 (hazard ratio, 0.31 [0.11-0.85] P=0.02) in the high RoPE score group (≥7)
  • PFO causality cannot be proven with 100% accuracy and other stroke contributing causes may still require investigation
  • the score doesn´t predict the benefit from the PFO closure; the benefit from closure depends on the probability that the PFO was causally related to the stroke and the likelihood that the stroke will recur
    • patients with a high RoPE score are more likely to have a ‘pathogenic’ PFO, but they also appear to have a lower risk of stroke recurrence
    • score that does not reflect anatomic characteristics of the PFO ((e.g., shunt size, presence of an atrial septal aneurysm) 
  • ⇒ the score should not be used in isolation to determine which patients with PFO should get closed
  • step 1 – use the RoPE score to predict which patients are likely to have had cryptogenic strokes that are attributable to PFO
  • step 2 – include other factors to decide whether PFO should be closed
Characteristic Points
no history of hypertension 1
no history of diabetes 1
no history of stroke or TIA 1
nonsmoker 1
cortical infarct on imaging 1
Age
12-29 5
30-39 4
40-49 3
50-59 2
60-69 1
≥ 70
0
Points (0-10)
  • maximum score 10 – a patient < 30 y without vascular risk factors, no history of stroke or TIA, and cortical infarct
  • minimum score 0 – a patient 70 y with vascular risk factors, history of stroke, and no cortical infarct
RoPE score Probability of PFO being the cause of stroke (95% CI)) Estimated stroke/TIA recurrence at 2 years
0-3 0% (0–4) 20% (12–28)
4 38% (25–48) 12% (6–18)
5 34% (21–45) 7% (3–11)
6 62% (54–68) 8% (4–12)
7 72% (66–76) 6% (2–10)
8 84% (79–87) 6% (2–10)
9-10 88% (83–91) 2% (0–4)
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