Introduction. PFO in ESUS patients may be incidental or pathogenic. Alternative mechanisms, such as covert atrial fibrillation, may be the actual stroke mechanism. The Risk of Paradoxical Embolism (RoPE) score was developed to estimate the probability that a PFO is pathogenic. We aimed at validating the RoPE score in a large ESUS population, and investigate the rate of AF detection during follow-up according to PFO status and RoPE score. Methods. The study was conducted retrospectively on three stroke registries with prespecified data collection: the Acute STroke Registry and Analysis of Lausanne (ASTRAL), the Athens Stroke Registry (ASR) and the Larissa Stroke Outcome Registry (LASTRO). Results. Among 455 ESUS patients (median age 59 years, 41% females, median follow-up 1.7 years) where PFO was searched, it was discovered in 40% (n=184). The prevalence of PFO increased with higher RoPE score values (Table). The performance of the RoPE score (AUC-ROC) was 0.75. The overall Kaplan-Meier estimate of 10-years AF detection and stroke recurrence were 26% (16.9-35%) and 34.4% (24-44.7%) respectively. The 10-year probability of AF detection was lowest in patients with PFO likely pathogenic (RoPE=7-10), intermediate in those with PFO likely incidental (RoPE=0-6) and highest in those without PFO (Figure). Stroke recurrence rate was non-significanly lower in PFO likely pathogenetic patient than in others. Conclusion: In this multicentre study of ESUS patient, the RoPE score was validated for discrimination of incidental and pathogenic PFO. Low RoPE scores also predict incidental AF during 10 year follow-up.
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