Should I listen to my doc and start an aspirin regimen to offset risks associated with PFO?
January 4, 2012 11:09 AM   Subscribe

I am a 25-year-old male. During a recent routine physical, my doctor discovered a heart murmur. Subsequent echocardiograms led to a diagnosis of patent foramen ovale (PFO). I have a history of migraines with aura, so it's kind of nice to know that this may be related. Anyway, my doctor said that I should immediately start a baby aspirin regimen to decrease my risk of a stroke. I also have a history of GI problems (IBS symptoms as a kid, occasional bleeding in the stool and other unpleasant things) and am therefore a little apprehensive about beginning the regimen. YANMD, but what do you guys think about whether the stroke risk for a 25-year-old male outweighs the GI risks associated with aspirin?
posted by Enneking to Health & Fitness (19 answers total)
 
You have, presumably, discussed the possible side effects if aspirin with your doctor. If your doctor still prescribed an aspirin regimen, the person with all of the information and expertise needed to answer this question already has.
posted by valkyryn at 11:14 AM on January 4, 2012 [1 favorite]


Ask your doctor this question.

But if it were me, I'd take the aspirin. They make aspirin with a coating to not upset the stomach, it might help a bit.
posted by royalsong at 11:15 AM on January 4, 2012 [1 favorite]


Of course I am not your physician--but if I were you I wold faithfully follow his advice. Bottom line for me is that bowels can be fixed--not so brains or heart muscle. I am overwhelming impressed at the rigorous clinical and laboratory research regarding the efficacy of aspirin in helping to reduce cardiovascular events. Good luck
posted by rmhsinc at 11:15 AM on January 4, 2012 [1 favorite]


Have you talked to your doctor about chewable baby aspirin? (Or was that what he suggested?)
posted by Lesser Shrew at 11:17 AM on January 4, 2012


If the aspirin causes you GI problems, you can stop taking it or consult your doctor about other options.
posted by mskyle at 11:25 AM on January 4, 2012


There are many options for avoiding GI side effects (including a number of options where you don't ingest the aspirin at all), whereas you do not have a lot of options for stroke prevention. Chat with a pharmacist, too, in case your doctor isn't up to speed on all the latest.
posted by Lyn Never at 11:25 AM on January 4, 2012


Remember, you're not assessing stroke risk in a 25-year-old male, you are assessing stroke risk in a 25-year-old male with PFO and a heart murmur. And as rhmsinc says, you can fix a GI problem; less so the aftereffects of a stroke.
posted by lulu68 at 11:30 AM on January 4, 2012 [1 favorite]


I do some research involving post-stroke patients (collaborative, so I'm hardly an expert, and I'm certainly not that kind of doctor, but I do have some experience). Seriously, take the aspirin, living as a post-stroke patient is one of the worst things I could imagine happening to me, any reduction of the risk of stroke is worth side effects that are merely uncomfortable. And talk to your doctor about the side effects of course.
posted by advil at 11:49 AM on January 4, 2012


You could always get a second opinion.
posted by chairface at 11:51 AM on January 4, 2012


Do a dedicated search on Medline Plus(National Library of Medicine) under aspirin. Look at the studies listed there on gastrointestinal effects. There are some studies that suggest that aspirin may have a beneficial effect on the GI tract.
posted by effluvia at 12:06 PM on January 4, 2012 [1 favorite]


I've treated several young people who have had strokes probably due to having a PFO. The youngest was 18 at the time of her stroke. When I saw her she couldn't speak at all and her writing/spelling had gone from great (she was training to be a teacher) to pretty poor. I would definitely take the aspirin or an equivalent treatment because it does happen to young people.
posted by kadia_a at 12:06 PM on January 4, 2012


I would ask for a referral to a pediatric cardiologist if I were in your shoes; they deal with a variety of holes in people's hearts all the time and can assess your risk of paradoxical embolism accurately. According to most textbooks, up to 30% of people under 30 and 20% of people over 30 have a PFO and usually suffer no problems. Also given your age and the potential problems of being on aspirin (not only your history of GI problems but presumably you are reasonably active physically and so are at risk for bleeding from various types of trauma) you may be a good candidate for device closure of your PFO, which is usually done by a pediatric cardiologist as well. You would still need to be on anticoagulants afterward, but not permanently. If even a few months of anticoagulation is not acceptable, then surgery is also an option; it is heart surgery but it is one of the safest heart surgeries there is. Does the doctor who recommended the aspirin know about your GI concerns? Is he a cardiologist? It might be reasonable to take aspirin, but your concerns are very valid; GI bleeds can be fatal, as can hemorrhagic strokes (which can happen after relatively minor trauma in patients taking aspirin or other antiplatelet drugs).

The good news is that in a young healthy patient all of these risks are very small; unless you have other health problems the chance of you having a major problem is remote no matter what therapy you choose. But you definitely need to discuss this in more detail with the doctor who diagnosed you, and consider a referral to a specialist if this is not a condition he sees and treats on a regular basis.
posted by TedW at 12:53 PM on January 4, 2012 [1 favorite]


Aspirin is a blood thinner. Did you explicitly discuss the aspirin regimen in regards to your bleeding/GI issues with your doctor?
posted by scody at 2:09 PM on January 4, 2012


Your PFO might be causing your IBS symptoms as well as your migraines:

abstract

A higher prevalence of cardiac right-to-left shunt through a patent foramen ovale (PFO) has been recently reported in the irritable bowel syndrome (IBS). At the same time, signs of ischemia in medullary cerebral microcirculation and the presence of excess sympathetic activity in peripheral circulation have been identified, both related with change in pain perception and autonomic dysfunction characteristic of IBS. Considering these findings together, the possible etiopathogenic role of PFO in the development of IBS can be proposed, because the paradoxical embolism characteristic of PFO could damage the cerebral and intestinal microcirculation, and that injury would be also amplified by the percentage of venous blood that shunts the pulmonary filter, producing an alteration in the metabolism of serotonin, pro-inflammatory bradykinins or neurotensin, substances with a proven etiopathogenic relationship with IBS.


There could be all kinds of upside for you in getting it fixed, but the Wikipedia article does mention some problems, too:

It has been shown that migraine frequency and severity is reduced if the hole is patched surgically.[73] Mark Reisman, cardiologist at Seattle's Swedish Medical Center explained an advantage to non-pharmacological migraine relief. He said, "In contrast to drugs, PFO closure appears highly effective against migraines and usually has no side effects".[74] Because PFO closure continues to prove successful, new devices are being produced to make the surgery easier to perform and less invasive.

Recent studies, however, have emphasised caution in relating PFO closure surgeries to migraines, stating that the favourable studies have been poorly-designed retrospective studies and that insufficient evidence exists to justify the dangerous procedure.[75][76] As well, at least one patient with infrequent migraines who underwent the surgery ended up with daily migraines for at least 6 months,[72] and others have reported short-term increases in migraine frequency and intensity following the surgery.[77][78][79]

posted by jamjam at 3:11 PM on January 4, 2012


There are a whole slate of new antithrombotic drugs coming on the market, from Pradaxa to rivaroxaban etc. They are of course a lot more expensive than aspirin, and I'm not sure if they would be indicated for your condition anyway, but it might be something to bring up with you doc.
posted by zachawry at 3:20 PM on January 4, 2012


This is a complex issue, and I would urge you to involve more physicians in handling this. Because you may be doing yourself little good simply following the advice of your GP. Doctors specialize for a reason. For example, you said that your doctor immediately suggested you take a baby aspirin - but has he tested you for a response to the aspirin? Because you may not be an aspirin responder - somewhere around 20% of stroke patients are not. And the result could be that you'll get a stroke anyway and on top of that you'll get GI issues:

Repeat Stroke More Likely in Aspirin Nonresponders

Also, someone suggested using enteric coated aspirin for gentler GI effects. In the latest studies, it seems the coating is not effective - it merely delays dissolution, so the effects are stronger further along the alimentary canal compared to non-coated. It's a wash. This is an evolving area of inquiry, so not all the data is in yet, but I'd be careful thinking you'll be any safer from GI side effects with a coated aspirin.

Further, I would be disappointed if the GP simply suggested an aspirin with no tests to see if you are suitable, nor any education as to how to take the aspirin. For example, you should not mix NSAIDs - ibuprofen (such as Advil) will negate aspirin's effects if taken too close to each other. And many other things.

Bottom line: you are faced with a complex problem. You need to fully explore your options, and it may be advisable to reach beyond just your GP, if s/he seems not to be on top of all the relevant issues.
posted by VikingSword at 3:44 PM on January 4, 2012 [1 favorite]


There is so much junk in this thread, you probably shouldn't listen to any of it besides having a discussion with your doctor about the risks and benefits.

One study shows that if you have a PFO, you're not more likely to have a stroke.

Another study looks at people who have had a stroke, and found that of those where they couldn't figure out why someone had the stroke, they had a PFO.

Aspirin might reduce your stroke risk, it might not, but it is definitely associated with increased bleeding (that's how it prevents strokes) and upsets some people's stomachs as well. 25 year-olds have very low (but not zero) stroke risk. You should discuss your baseline risk with your doctor along with how much aspirin might reduce your risk. If your risk is 0.8%, if aspirin made your risk 10 times lower (0.08%), would that be worth it? That's a decision you have to make.
posted by gramcracker at 8:08 PM on January 4, 2012


Response by poster: Thanks everyone for your input. I'm a little overwhelmed by the conflicting information in all directions and I think those of you who have suggested further consultations with a specialist are probably right. The problem is, though I live in New York City, I continue to see doctors in my small hometown in the Midwest. There are several hospitals there and many presumably quality cardiologists and so forth, but as far as family physicians/general practitioners, I've had mostly bad luck (they've been unresponsive, cursory, dismissive, etc.)

Furthermore, when I turn twenty-six (soon) I will be dropped from my parents' insurance. Though I'm set to get insurance through a job about the same time I'm off my parents', I may also be leaving the country to take the job.

My family physician did recommend I check in with a cardiologist once a year. Is this something that I can wait on until next year when, presumably, I'll be more settled and be able to speak directly with a cardiologist?
posted by Enneking at 9:47 AM on January 11, 2012


Best answer: I am not surprised at your being overwhelmed by conflicting information; I did a quick literature search for the latest recommendations for treating PFO and there is no real consensus, even in patients who have had a prior stroke. Having said that, there are clear indications for closure of a PFO but they are related more to hemodynamics than to stroke or migraine. To some extent you will need to sit down with someone who can take the time to explain the risks and benefits of different approaches to this problem and then help you decide what approach works for you. You ask about when to see a cardiologist; medically there is no reason to rush, but given your concern about this as well as some uncertainty about your access to care in the future I would suggest doing it sooner.

You mention being from the Midwest; if by any chance you are near Minnesota, that is where a number of advances in treating congenital heart disease were made (both at the Mayo Clinic and University of Minnesota) and there are plenty of cardiologists experienced in dealing with PFOs there. It is a common enough condition that you should be able to find a good cardiologist just about anywhere. As I mentioned above, a pediatric cardiologist might be a better option than an adult cardiologist; a number of them see adult patients with conditions like PFO.

I work with pediatric cardiologists on a regular basis and if you want I can see if they have any suggestions for referrals in your area; feel free to memail me for that or any other info I can help you find.
posted by TedW at 10:29 AM on January 11, 2012 [1 favorite]


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