ROPE score

(Risk of Paradoxical Embolism)

David Goldemund M.D.
Updated on 24/04/2024, published on 01/06/2023
  • 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
Patent Foramen Ovale (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
Characteristic Points
no history of hypertension 1
no history of diabetes 1
no history of prior stroke or TIA
non-smoker 1
cortical infarct on imaging 1
12-29 5
30-39 4
40-49 3
50-59 2
60-69 1
≥ 70
Points (0-10)
  • 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
RoPE score The probability that PFO is 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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Risk of Paradoxical Embolism (RoPE) Score