History and exam
Key diagnostic factors
common
atrial septal aneurysm
A risk factor.
congenital heart conditions
A risk factor.
cerebrovascular accident (CVA) at ages <60 years
In order to prove definitively that the PFO is a causal factor, patients have a right-sided thrombus (e.g., deep vein thrombosis), presence of PFO, evidence of systemic embolism (e.g., CVA or intra-arterial embolism) and thrombus crossing through the PFO (thrombus-in-transit).[19]
It is extremely rare to have all four factors present, and thus the presence of CVA and PFO with an absence of other obvious sources of embolism is presumptively diagnostic of paradoxical embolism.
PFO is present in all age groups, but is more likely to be the cause of cryptogenic stroke in younger patients.
abnormal cardiac examination
A systolic murmur (sometimes fixed) and splitting of the second heart sound is found in secundum atrial septal defect.
uncommon
deep vein thrombosis
Increases the likelihood of paradoxical embolism in patients with a PFO.
Other diagnostic factors
uncommon
decompression symptoms related to diving
Venous to arterial gas embolism is seen in some divers as part of decompression from coming to the ocean surface while deep sea diving.
cold sensation in limb
May be evidence of systemic embolism (e.g., CVA or intra-arterial embolism).
limb pain
May be evidence of systemic embolism (e.g., CVA or intra-arterial embolism).
shortness of breath while upright in platypnoea-orthodeoxia syndrome
In platypnoea-orthodeoxia syndrome, patients usually experience shortness of breath upon sitting and relief upon assuming a recumbent position.
Risk factors
strong
atrial septal aneurysm
Associated with a greater frequency of PFO; the combination with PFO is associated with a greater incidence of recurrent stroke.[12]
congenital heart conditions
These include Ebstein anomaly and tricuspid atresia.
Some congenital heart defects elevating right atrial pressure may lead to stretching and persistent patency of the fossa ovalis.
weak
family history of migraine
Studies suggest a link between family history of migraine and presence of PFO.[13]
migraine
Studies suggest a link between migraine and presence of PFO.[14]
family history of PFO
Small studies carried out in families of individuals with PFO show an increased prevalence.[13]
obstructive sleep apnoea
Studies have found an increased prevalence in patients with obstructive sleep apnoea, possibly due to increased right atrial pressures.[15]
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