BACKGROUND
The vascular component of the migraine-specific physiologic profile and the observed adverse cardiovascular risk profile in migraineurs suggest an association between migraine and cardiovascular disease (CVD). In women, migraine has been associated with increased risk of CVD, including coronary events. Compatible data in men are lacking.


METHODS
Prospective cohort study of 20 084 men aged 40 to 84 years participating in the Physicians' Health Study. In yearly questionnaires, men were asked for information on migraine, risk factors, and the occurrence of study end points. We classified men as having migraine if they indicated migraine during the first 5 years, after which time follow-up began. Information on aura was not available. All the men were free of CVD at the start of follow-up. During a mean of 15.7 years, we followed up participants for the occurrence of a first major CVD event (nonfatal ischemic stroke, nonfatal myocardial infarction, or death from ischemic CVD). We also evaluated the individual end points, coronary revascularization, and angina.


RESULTS
A total of 1449 men (7.2%) reported migraine, and during follow-up, 2236 major CVD events occurred. Compared with nonmigraineurs, men who reported migraine had multivariable-adjusted hazard ratios (95% confidence intervals) of 1.24 (1.06-1.46; P = .008) for major CVD, 1.12 (0.84-1.50; P = .43) for ischemic stroke, 1.42 (1.15-1.77; P<.001) for myocardial infarction, 1.05 (0.89-1.24; P = .54) for coronary revascularization, 1.15 (0.99-1.33; P = .068) for angina, and 1.07 (0.80-1.43; P = .65) for ischemic cardiovascular death.


CONCLUSION
In this large prospective cohort of apparently healthy men, migraine was associated with increased risk of major CVD, which was driven by increased risk of myocardial infarction.

Migraine and risk of cardiovascular disease in men. Arch Int Med

Cardiogenic brain embolism

Managing young and middle-aged patients with cryptogenic ischemic stroke and a patent foramen ovale (PFO) is a common clinical dilemma for neurologists, cardiologists, and primary care physicians. Each year, ≈18 000 patients in the United States and 345 000 worldwide, aged 18 to 60, present with a PFO and an embolic stroke of otherwise undetermined source (Figure 1).1–5 Leading treatment options to prevent stroke recurrence include antiplatelet medications, anticoagulant medications, and percutaneously placed PFO closure devices. Lacking randomized trial data, choosing among these options was long a quandary for physicians. But major new trial results in 2017 to 2018,6–9 added to earlier trials reported in 2012 to 2013,10–12 have transformed the evidential foundation for PFO management. This topical review appraises and synthesizes the accumulated trial findings and considers how they may best inform physician and patient treatment decision-making.



Figure 1. 
Annual incidence of cryptogenic ischemic stroke in young and middle-aged adults with patent foramen ovale (PFO). Broad estimates of annual incidence in ( A ) United States; ( B ) globally.1–5



Right-to-left shunts enable thrombi that form in, and dislodge from, the venous system to bypass filtration in the pulmonary vasculature, paradoxically cross to the arterial tree, and travel to and occlude recipient cerebral arteries. PFOs are the most common causes of right-to-left shunts, present in about one quarter of all adults. During fetal life, the interatrial septum separating the right and left atria initially forms with a tunnel, the foramen ovale, that enables maternally oxygenated blood to bypass the fetal pulmonary circulation and nourish arterial beds directly. This interatrial passage closes in most individuals during the first 3 months after birth. However, in about one quarter of the population, the passage remains patent lifelong. The mean diameter of persisting PFOs is 4.9 mm (range, …

Patent Foramen Ovale Closure Versus Medical Therapy for Cryptogenic Ischemic Stroke: A Topical Review.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

https://bmjopen.bmj.com/content/bmjopen/8/7/e023761.full.pdf

Patent foramen ovale closure, antiplatelet therapy or anticoagulation in patients with patent foramen ovale and cryptogenic stroke: a systematic review and network meta-analysis incorporating complementary external evidence.

The occurrence of clinically silent cerebral infarcts (SCIs) in individuals affected by cardiac disease and after invasive cardiac procedures is frequently reported. Indeed, atrial fibrillation, left ventricular thrombus formation, cardiomyopathy, and patent foramen ovale have all been associated with SCIs. Furthermore, postprocedural SCIs have been observed after left cardiac catheterization, transcatheter aortic valve implantation, CABG surgery, pulmonary vein isolation, and closure of patent foramen ovale. Such SCIs are often described as precursors to symptomatic stroke and are associated with cognitive decline, dementia, and depression. Increased recognition of SCIs might advance our understanding of their relationship with heart disease and invasive cardiac procedures, facilitate further improvement of therapies or techniques aimed at preventing their occurrence and, therefore, decrease the risk of adverse neurological outcomes. In this Review, we provide an overview of the occurrence and clinical significance of, and the available diagnostic modalities for, SCIs related to cardiac disease and associated invasive cardiac procedures.

Pei-Chen Ning

Papers

The Brain’s Heart – Therapeutic Opportunities for Patent Foramen Ovale (PFO) and Neurovascular Disease