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Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline

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      Most cited references 33

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      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.

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        Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

        The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines. © 2014 American Heart Association, Inc.
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          GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation's direction and strength.

          In the GRADE approach, the strength of a recommendation reflects the extent to which we can be confident that the composite desirable effects of a management strategy outweigh the composite undesirable effects. This article addresses GRADE's approach to determining the direction and strength of a recommendation. The GRADE describes the balance of desirable and undesirable outcomes of interest among alternative management strategies depending on four domains, namely estimates of effect for desirable and undesirable outcomes of interest, confidence in the estimates of effect, estimates of values and preferences, and resource use. Ultimately, guideline panels must use judgment in integrating these factors to make a strong or weak recommendation for or against an intervention. Copyright © 2013 Elsevier Inc. All rights reserved.

            Author and article information

            [1 ]Department of guideline development and research, Dutch College of General Practitioners, Utrecht, The Netherlands
            [2 ]McMaster University, Hamilton, Canada
            [3 ]Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
            [4 ]Department of Medicine, University of Toronto, Toronto, Ontario, Canada
            [5 ]Norwegian Institute of Public Health, Oslo, Norway
            [6 ]Department of Medicine, Innlandet Hospital Trust - division Gjøvik, Norway
            [7 ]University of Washington, Seattle, District of Colombia, USA
            [8 ]Division of Neurology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
            [9 ]University of California Davis, Sacramento, CA, USA
            [10 ]All India Institute of Medical Sciences, New Delhi, India
            [11 ]University Medical Center of Groningen, Groningen, The Netherlands
            [12 ]Departments of Anesthesia & Perioperative Medicine, and Epidemiology & Biostatistics, Western University, London, Canada
            [13 ]Division General Internal Medicine, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
            [14 ]NUI Galway, Galway, Ireland
            [15 ]Oslo University Hospital, Oslo, Norway
            [16 ]Las Vegas, Nevada, USA
            [17 ]Boulder, Colorado, USA
            [18 ]Welwyn, Hertfordshire, UK
            [19 ]Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
            Author notes
            Correspondence to: T Kuijpers t.kuijpers@
            Role: methods editor
            Role: (chair), non-interventional cardiologist
            Role: general internist, methodologist
            Role: general internist, professor
            Role: cardiologist
            Role: patient liaison expert
            Role: internal medicine and cardiology physician
            Role: stroke physician
            Role: non-interventionol cardiologist
            Role: interventional cardiologist
            Role: interventional cardiologist
            Role: clinical epidemiologist
            Role: general internist
            Role: stroke physician
            Role: interventional cardiologist
            Role: patient partner
            Role: patient partner
            Role: patient and carer partner
            Role: general internist, assistant professor
            Role: distinguished professor
            The BMJ
            BMJ Publishing Group Ltd.
            25 July 2018
            : 362
            30045912 6058599 kuit043649 10.1136/bmj.k2515
            Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to

            This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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