PFO Closure Risk (RoPE) Score Calculator
- PFO Closure Risk (RoPE) Score: Explanation and Clinical Context
The RoPE (Risk of Paradoxical Embolism) score is a validated 10-point tool designed for patients with cryptogenic ischemic stroke in whom a patent foramen ovale (PFO) is detected. It estimates how likely the index stroke is causally related to the PFO (rather than incidental) and contextualizes the expected 2-year recurrence risk under medical management. The score assigns points for younger age and the absence of vascular risk factors (no hypertension, no diabetes, nonsmoking), no prior stroke/TIA, and the presence of a cortical infarct on neuroimaging. Higher scores (especially ≥7) indicate a higher probability that the stroke is PFO-related, whereas lower scores suggest the PFO is more likely incidental.
Importantly, as the score increases the PFO-attributable fraction rises (approaching ~88% for scores 9–10), while the observed 2-year recurrence tends to be lower compared with low-score strata. These relationships reflect that patients whose index event is most plausibly PFO-mediated often have fewer competing stroke mechanisms and a relatively benign recurrence profile on medical therapy, whereas patients with low scores likely harbor non-PFO causes with higher recurrence. The RoPE score does not incorporate anatomic PFO risk features (e.g., large right-to-left shunt or atrial septal aneurysm) or concurrent venous thromboembolism. For closure decision-making, many groups therefore pair RoPE with an anatomic/clinical framework (e.g., PASCAL) and randomized-trial evidence, integrating patient age, stroke mechanism work-up, PFO features, and bleeding/device considerations.
References:
Kent DM, Ruthazer R, Weimar C, et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology. 2013;81(7):619–625. PMC3775694.
Thaler DE, Ruthazer R, Weimar C, et al. The Risk of Paradoxical Embolism (RoPE) Study. J Am Heart Assoc / Neurology-related consortium resources; overview and pooled database methods. 2012–2014. (See PMCID: PMC4060865; and related analyses).
Thaler DE, Kent DM. Patient Selection for PFO Closure Based on the RoPE Study. Cardiac Interventions Today. 2014; March/April:60–65. (Explains Bayes approach and strata ranges 0%–88%).
Kent DM, Mir H, et al. Risk of Paradoxical Embolism (RoPE)–Estimated Attributable Fraction and Treatment Benefit. Stroke. 2020;51: in press at time; demonstrates correlation of RoPE-estimated attributable fraction with closure benefit.
NCBI Bookshelf. RoPE Score and PASCAL classifications – table synopsis of variables and interpretive ranges.
Kim JS, et al. Patent Foramen Ovale and Stroke. Korean Circ J. 2022; Table: PFO-attributable fraction and 2-year recurrence by RoPE strata (values used in this tool).
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