Prevalence of patent foramen ovale (PFO) in patients with angina and documented coronary artery vasospasm

Patent Foramen Ovale (PFO) and atrial septal defect (ASD) have been associated
with the occurrence of paradoxical embolism. Current guidelines and position
reports recommend diagnostic work-up in young patients with cryptogenic stroke
and closure of PFO in selected cases. In addition to the association between
PFO and cryptogenic stroke, there are many reports of patients with a PFO that
suffer a systemic arterial embolism causing arterial occlusion of extremities,
renal infarcts and acute myocardial infarction with paradoxical embolism in the
coronary artery.
In addition, PFO has been associated with migraine with aura, suggesting that
vaso-active components of the venous circulation, when bypassing the lungs
through a right-to-left-shunt (RLS), may modulate the cerebral microcirculation
causing migraine. Although recent randomized trials have not demonstrated that
PFO closure is superior to medical therapy in migrainers, PFO closure has been
shown to abolish migraine in 9% of patients and reduce the number of monthly
migraine days with 3 days in a recent meta-analysis.
In a recent study, an association was demonstrated between migraine and
coronary spasm, although there was no association with coronary heart disease
(CHD) events. Importantly, anti-migraine medication such as triptans may cause
coronary spasm. RLS can be a trigger for the occurrence of migraine headaches
and is postulated to be a trigger for episodes of angina complaints due to
coronary spasm.

The main objective of this study is to assess the prevalence of PFO and RLS in
patients with angina and documented coronary artery vasospasm.

This is a single-center, prospective, cohort study. Open label with follow up
at 6 months.

After signing informed consent, patients will undergo transthoracic
echocardiography (TTE) with intravenous agitated-saline to evaluate the
presence of RLS. Patients with a PFO and RLS will be invited to undergo
exercise testing including VO2max and oxygen saturation measurement. Patients
will be surveyed with the Seattle Angina Questionnaires (SAQ) and Migraine
Disability Assessment Questionnaire (MIDAS). They will report general
well-being, daily activities, and episodes of angina and migraine. Patients
with RLS will be asked to measure oxygen saturation with a pulsoximeter at set
intervals during the follow-up period, e.g. before and during exercises.