Summary
Definition
History and exam
Key diagnostic factors
- atrial septal aneurysm
- congenital heart conditions
- cerebrovascular accident (CVA) at ages <60 years
- abnormal cardiac examination
- deep vein thrombosis
Other diagnostic factors
- decompression symptoms related to diving
- cold sensation in limb
- limb pain
- shortness of breath while upright in platypnea-orthodeoxia syndrome
Risk factors
- atrial septal aneurysm
- congenital heart conditions
- family history of migraine
- migraine
- family history of PFO
- obstructive sleep apnea
Diagnostic tests
1st tests to order
- transthoracic echo with color Doppler and contrast injection
- transesophageal echo with color Doppler and contrast injection
Tests to consider
- intracardiac echo
- ultrasound lower extremity
- MRI lower extremity
- tilt-table transesophageal echo
Emerging tests
- transcranial Doppler
Treatment algorithm
asymptomatic with low risk of thrombotic event (not in high risk occupation)
asymptomatic with high risk of thrombotic event (not in high-risk occupation)
cryptogenic stroke
high-risk occupation
Contributors
Authors
Kul Aggarwal, MD, MRCP, FACC
Professor of Clinical Medicine
University of Missouri
Columbia
MO
Disclosures
KA is the author of a reference cited in this topic.
Poorna R Karuparthi, MD, FACC
Clinical Assistant Professor
University of Missouri Hospital
Division of Cardiology
University of Missouri
Columbia
MO
Disclosures
PRK declares that he has no competing interests.
Acknowledgements
Professor Kul Aggarwal and Poorna R Karuparthi would like to gratefully acknowledge Dr Vibhuti Singh, a previous contributor to this topic.
Disclosures
VS declares that he has no competing interests.
Peer reviewers
Navin Nanda, MD
Professor of Medicine
Director Heart Station and Echocardiography Laboratories
University of Alabama at Birmingham
Birmingham
AL
Disclosures
NN declares that he has no competing interests.
Andrew Turley, MB ChB
Cardiology Specialist Registrar
The James Cook University Hospital
Middlesbrough
UK
Disclosures
AT declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015 Aug;28(8):910-58.Full text Abstract
Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med. 2013 Mar 21;368(12):1083-91. Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Arteriovenous malformation (AVM) in the lung
More DifferentialsGuidelines
- 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack
- 2020 ESC guidelines for the management of adult congenital heart disease
More GuidelinesPatient information
Migraine
More Patient information
Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer