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The Correct Answer is C!

Knowledge to Practice, in collaboration with Mayo Clinic, offers online board review and lifelong learning products in Internal Medicine. With a full pre-assessment, you can identify the topics you’ve mastered and focus your time on topics where you need it the most. Our products have been shown to increase knowledge 75% more than traditional methods in less time.1

Question:

A 42 year-old asymptomatic woman is evaluated as part of a general health evaluation. She is an avid runner. A cardiac murmur is appreciated on physical examination and echocardiography is requested. This reveals normal cardiac chamber sizes, mild mitral valve regurgitation, normal right heart pressures, and a patent foramen ovale.

The next best step for this patient should be which of the following?

  1. Percutaneous closure of patent foramen ovale
  2. Warfarin titrated to international normalized ratio 2-3
  3. Reassurance
  4. Transesophageal echocardiography

Rationale:

Reassurance is the most appropriate management at this point. Patent foramen ovale (PFO) is a very common finding, present in 20-25% of the normal adult population. Most patients with small PFOs remain asymptomatic, and only minor shunting occurs with little effect on right heart hemodynamics such as RA and RV volume overload. However, PFOs have been associated with cryptogenic stroke, migraines, and sleep apnea, leading to questions about how they should be managed. Diagnosis of PFO can be made using echocardiography. Transesophageal echocardiography is generally the test of choice to detect a PFO. Transthoracic echocardiography (TTE) can also be used, but the sensitivity is much lower, estimated at about 46%. In this asymptomatic patient, who has already had TTE that identified the lesion and adequately assessed hemodynamics, obtaining additional TEE is unnecessary. Generally, intervention for PFO is not indicated unless a patient is symptomatic or PFO is associated with cryptogenic stroke. Three recent randomized trials did not manage to demonstrate benefit of PFO closure compared to medical therapy for secondary prevention of stroke. However, in a meta-analysis, PFO closure appears to be superior to medical therapy for secondary prevention of stroke. If medical therapy is chosen, a recent meta-analysis showed no difference between the use of oral anticoagulation and antiplatelet therapy in secondary stroke prevention, and choice of therapy should be dictated by the patient’s other comorbidities such as venous thromboembolic disease, atrial fibrillation, heart disease, etc. Current AHA guidelines do not support PFO closure in the setting of cryptogenic stroke or TIA unless there is concomitant DVT identified.

1.  Source: "Comparative Analysis of Pre/Post Assessments of Live/Didactic Course Attendees when compared to Mico-Learning/Online Course Users., "Knowledge to Practice, 2017.

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