ADD-ONS / SCALES AND SCORES

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→ Patient Selection for PFO Closure Based on the RoPE Study

→ Paradoxical embolism and stroke

• the prevalence of the patent foramen ovale (PFO) in the general population is approximately 25%
• PFO is overrepresented in the population with cryptogenic stroke (CS) ( (prevalence of approx. 50%)
• the discovery of a PFO in an individual stroke patient with an otherwise occult etiology is not synonymous with a diagnosis of paradoxical embolism
• the RoPE score has been proposed to help establish the relationship between cryptogenic stroke and PFO

• validation indicates 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% certainty; other causes of stroke may still require investigation
• the score does not predict the benefit of PFO closure; the benefit depends on the likelihood that the PFO was causally related to the stroke and and the probability of stroke recurrence
  • 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
    
  • the RoPE score that does not reflect anatomical characteristics of the PFO ((e.g., shunt size, presence of atrial septal aneurysm);  these variables were included in the modified AF-RoPE score
    
• ⇒ the score should not be used in isolation to determine which patients with a PFO should undergo a closure procedure
  

• step 1 – use the RoPE score to predict which patients are likely to have experienced cryptogenic strokes attributable to PFO
• step 2 – incorporate additonal factors to decide whether to proceed with PFO closure
  

• maximum score 10 – a patient < 30 years of age without vascular risk factors, no history of stroke/TIA, and with a cortical infarct
• minimum score 0 – a patient ≥ 70 years of age with vascular risk factors, a history of stroke, and no cortical infarct