Current Treatment Options in Cardiovascular Medicine

Publications in this journal

• Article: The Role of B-Type Natriuretic Peptide Testing in Guiding Outpatient Heart Failure Treatment.

  Noreen P Kelly, James L Januzzi
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  ABSTRACT: OPINION STATEMENT: While heart failure (HF) treatment guidelines exist, there are significant gaps in their implementation owing in part to the lack of objective data to help guide clinicians in their medical decision-making. B-type natriuretic peptide (BNP) and its amino-terminal equivalent (NT-proBNP) are objective markers of HF prognosis, are useful to monitor response to treatment in outpatients with HF, and may have a role in "guiding" HF care as well. Successful BNP or NT-proBNP guided HF treatment requires regular attempts to reach and maintain target values (BNP ≤ 125 pg/mL or NT-proBNP ≤ 1000 pg/mL). This may be achieved through lifestyle modifications, exercise programs, medication adjustments, and therapeutic interventions shown to reduce morbidity and mortality in HF patients. Failure to achieve biomarker targets portends a worse prognosis, proportional to the lowest achieved natriuretic peptide concentration; in those with significant biomarker "nonresponse," prognosis is poor, and alternative therapeutic strategies should be considered.
  Current Treatment Options in Cardiovascular Medicine 05/2013;
• Article: Conduction Disorders after Transcatheter Aortic Valve Implantation: A Focused Review.

  Kelly M W McDonnell, Richard K Shepard
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  ABSTRACT: OPINION STATEMENT: Transcatheter aortic valve implantation (TAVI) is a less invasive approach to aortic valve replacement than traditional open chest surgery. It has been very successful in elderly and sick patients who might have otherwise been turned down for surgery. However, many patients who have the procedure develop conduction disease, including new LBBB or complete heart block, and may need permanent pacing or ongoing follow-up to monitor for worsening conduction problems. Here we discuss the risk for conduction disease with TAVI, identifying which patients may need a pacemaker or long-term rhythm follow-up, and methods to decrease the risk of worsening conduction.
  Current Treatment Options in Cardiovascular Medicine 05/2013;
• Article: Assessing the Impact of Heart Failure Therapeutics on Quality of Life and Functional Capacity.

  Eldrin F Lewis
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  ABSTRACT: OPINION STATEMENT: Chronic heart failure (CHF) is an increasingly common disorder with major impact on morbidity and mortality. Goals of therapy include improving survival, attenuating progression of disease, improving functional capacity, and improving health-related quality of life (HRQL). Although there are multiple HRQL instruments that are psychometrically valid, concerns exist on the ability to reliably measure HRQL concepts. Nevertheless, there has been an emphasis on improving HRQL and thus novel therapies and clinical trials have included HRQL assessment routinely. Nonpharmacologic interventions have made a greater impact on HRQL, including the use of transcutaneous aortic valve replacement, left ventricular assist devices, and cardiac resynchronization devices. Pharmacologic therapies have resulted in modest improvements in HRQL and these improvements are often not clinically meaningful to the patient and not lasting beyond 6 months. As novel therapies are developed for CHF patients, researchers must: (a) identify mechanisms that may meaningfully improve HRQL, (b) develop better instruments to measure HRQL, and (c) target the right population with enough impairment in their sense of well-being to enable an intervention to work. The recent publication of the Food and Drug Administration Draft Guidance for Use of Patient-Reported Outcome measures in clinical trials has served as the foundation for more robust trial design using these HRQL measures.
  Current Treatment Options in Cardiovascular Medicine 04/2013;
• Article: Appropriate and Inappropriate Use of Dronedarone in 2013.

  Gerald V Naccarelli
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  ABSTRACT: OPINION STATEMENT: Dronedarone is a multichannel blocking antiarrhythmic agent that has been shown to prevent atrial fibrillation/flutter (AF/AFl) recurrences in several multi-center trials. In the ANDROMEDA trial, dronedarone treatment increased mortality and cardiovascular hospitalizations patients with decompensated heart failure. In the ATHENA trial, dronedarone was used in elderly high risk patients with paroxysmal or persistent AF/AFl, excluding those with advanced heart failure, cardiovascular hospitalizations were significantly reduced. Dronedarone increased mortality and cardiovascular hospitalizations in a different patient group with permanent AF/AFl. Although organic toxicity from the drug is very rare, post-marketing data has reported rare hepatic toxicity associated with dronedarone use. Current guidelines position dronedarone as a front-line antiarrhythmic in many patients with AF/Fl. However, dronedarone should not be used in patients with advanced heart failure or in permanent AF. Clinical trial results have helped us define appropriate and inappropriate candidates for dronedarone.
  Current Treatment Options in Cardiovascular Medicine 04/2013;
• Article: How to Manage a High Defibrillation Threshold in ICD Patients: and Does it Really Matter?

  Maria Vittoria Matassini, Jeff S Healey
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  ABSTRACT: OPINION STATEMENT: In the 30 years since its introduction, implantable cardioverter defibrillator (ICD) hardware and programming has evolved greatly. Coupled with a better understanding of how patient factors and anti-arrhythmic drug therapy affect ICD function, these changes have resulted in a modern ICD system which is highly effective at terminating ventricular arrhythmias. This has led to a marked decrease in the conduct of intraoperative defibrillation testing. Still, clinicians are faced with patients who have had unsuccessful intraoperative defibrillation testing or who have experienced one or more failed clinical shocks for ventricular arrhythmias. Thus, clinicians caring for ICD patients must understand the expected performance of modern ICD systems, understand the issues with intraoperative defibrillation testing, and have a strategy for dealing with patients when their ICD has failed to terminate a clinical or induced ventricular arrhythmia. This review will focus on the clinical approach to such patients, including trouble-shooting and system revision.
  Current Treatment Options in Cardiovascular Medicine 04/2013;
• Article: Optimal Strategies Including Use of Newer Anticoagulants for Prevention of Stroke and Bleeding Complications Before, During, and After Catheter Ablation of Atrial Fibrillation and Atrial Flutter.

  Prashant D Bhave, Bradley P Knight
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  ABSTRACT: OPINION STATEMENT: Anticoagulation is a key component of peri-procedural care for patients undergoing catheter ablation for atrial fibrillation (AF) and atrial flutter (AFL). The timing of discontinuation and re-initiation of anticoagulants in the peri-procedural time frame is an important consideration in trying to minimize the risk of stroke and procedure-related bleeding. Until recently, options for oral anticoagulation were limited to warfarin, which typically requires 4-5 days before a therapeutic International Normalized Ratio (INR) is achieved. Therefore, patients deemed to have a high risk of peri-procedural stroke had to either have their procedure performed with a therapeutic INR, or with cessation of warfarin and the adjunctive use of bridging heparinoids. Recently, however, three novel oral anticoagulant agents, each with a rapid onset of action, have been approved by the FDA for use in thromboembolism prophylaxis in patients with AF and AFL. These new drugs (dabigatran, rivaroxaban, and apixaban) broaden the menu of options with regard to peri-procedural anticoagulation strategies that can be employed for ablation of AF and AFL.
  Current Treatment Options in Cardiovascular Medicine 04/2013;
• Article: PFO Closure for Cryptogenic Stroke: Review of New Data and Results.

  Shyam Rao, Cathy Sila
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  ABSTRACT: OPINION STATEMENT: Observational studies over 20 years have suggested that a patent foramen ovale (PFO) is an important cause of cryptogenic stroke in young individuals; case series and registries suggest that PFO closure confers superior protection from recurrent transient ischemic attack (TIA) and stroke. Recently completed randomized clinical trials did not confirm this hypothesis, but have provided reassurance that the risk of recurrent stroke is low at 1.5 %/yr. A target subset that may benefit are those with ischemic stroke, a large right-to-left shunt, and an atrial septal aneurysm. Further study is needed to determine the optimum strategy to reduce the long-term stroke risk in a lifetime of varying situational risk factors and temporary interruptions of medical therapies.
  Current Treatment Options in Cardiovascular Medicine 04/2013;
• Article: Combination Aspirin and Clopidogrel for Secondary Prevention of Ischemic Stroke.

  Thalia S Field, Makoto Nakajima, Oscar R Benavente
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  ABSTRACT: OPINION STATEMENT: Though antiplatelet agents are the mainstay of antithrombotic therapy for secondary prevention of noncardioembolic cerebral ischemic events, the efficacy of combination aspirin and clopidogrel has yet to be clarified by clinical trials. Current evidence suggests that there is no role for long-term combination of aspirin/clopidogrel for secondary stroke prevention. Recent preliminary data from the CHANCE (Clopidogrel in High-risk Patients with Acute Non-disabling Cerebrovascular Events) trial suggests that stroke recurrence at 90 days is reduced by a short course (21 days) of combination aspirin/clopidogrel initiated within 24 hours of minor stroke or TIA (Transient Ischemic Attack) compared with aspirin alone [1••] (Table 1). Other ongoing trials, which are also investigating the role of short-term combination antiplatelet therapy initiated immediately after minor stroke and TIA, will determine if these findings will be replicated.
  Current Treatment Options in Cardiovascular Medicine 03/2013;
• Article: Diagnosis and Misdiagnosis of Cerebrovascular Disease.

  Vasileios-Arsenios Lioutas, Shruti Sonni, Louis R Caplan
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  ABSTRACT: OPINION STATEMENT: Stroke is the leading cause of disability and the third leading cause of death in the USA. Ischemic and hemorrhagic strokes must be distinguished since treatment is quite different. Ischemic strokes account for 80 % of the total and recent advances in management of brain ischemia have added valuable options to the physicians' armamentarium. Wise selection and targeted treatment of patients is of paramount importance. Properly treated patients benefit significantly, while those erroneously diagnosed as ischemic stroke are exposed to potentially harmful side effects of therapy. Stroke can present in the form of several different clinical syndromes some of which are difficult to identify. Conversely, there are numerous conditions whose clinical presentation closely resembles stroke, also known as stroke mimics. Ancillary testing, especially imaging, is a crucial part of diagnostic evaluation, while clinical judgment, thorough knowledge of cerebrovascular anatomy and familiarity with characteristic stroke syndromes remain indispensable even in this era of technological advance.
  Current Treatment Options in Cardiovascular Medicine 03/2013;
• Article: Advances in Imaging of Intracranial Atherosclerotic Disease and Implications for Treatment.

  Fan Z Caprio, Shyam Prabhakaran
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  ABSTRACT: OPINION STATEMENT: Intracranial atherosclerotic disease (ICAD) is one of the most common causes of ischemic stroke worldwide and is associated with a high risk of recurrent stroke despite aggressive therapy. ICAD may lead to cerebral ischemia through a variety of mechanisms, the interactions of which are largely unknown. The use of endovascular therapy for the prevention of stroke related to severe ICAD has been studied but was associated with a higher risk of recurrent stroke and death in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study. With advances in diagnostic testing, it may be possible to better delineate the specific mechanism of stroke from ICAD and identify those patients at higher risk for recurrent ischemia. There may be a subset of patients less responsive to medical interventions, such as those with hemodynamic failure as opposed to those with perforator syndromes, who would benefit from medical plaque stabilization or safer endovascular approaches such as angioplasty alone. These will need to be tested in future clinical trials. Overall, symptomatic ICAD remains a high risk condition with suboptimal treatment options.
  Current Treatment Options in Cardiovascular Medicine 03/2013;
• Article: Management of Asymptomatic Carotid Artery Stenosis.

  Marc P Bonaca, Joshua Beckman
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  ABSTRACT: OPINION STATEMENT: Patients with atherosclerotic asymptomatic carotid artery disease are at a heightened risk of major adverse cardiovascular events including ischemic stroke. Intensive risk factor modification, including lifestyle interventions and the use of evidence based medical therapies, reduces the risk of adverse cardiovascular events in this population. Carefully selected patients with severe asymptomatic carotid stenosis may benefit from carotid endarterectomy or stenting. Patient and lesion characteristics may help to carefully select patients most likely to benefit from revascularization. Emerging therapies, including novel lipid lowering therapies, anti-platelet therapies, and anti-coagulant therapies, may further reduce the risk of adverse cardiovascular events in patients with stable atherosclerotic disease. The most important aspect of the management of asymptomatic carotid artery stenosis is reducing the overall cardiovascular risk of the patient.
  Current Treatment Options in Cardiovascular Medicine 03/2013;
• Article: Treatment of Bleeding Complications When Using Oral Anticoagulants for Prevention of Strokes.

  Frank Akwaa, Alex C Spyropoulos
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  ABSTRACT: OPINION STATEMENT: Major bleeding in patients taking oral anticoagulants for stroke prevention can progress to catastrophic bleeding if it is not controlled. This is especially of concern if the bleeding is related to the use of a novel oral anticoagulant (NOAC) such as dabigatran or rivaroxaban, given the dearth of literature addressing the reversal of their anticoagulant effects. The goal of treatment is to prevent progression to catastrophic hemorrhage or exsanguination, and decrease bleeding-related morbidity and mortality. Clinical decisions in such instances should be made in a timely fashion to address the necessity for intervention. Animal models have shown potential for the use of 'fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) in reversing bleeding related to novel oral anticoagulants. However, there is paucity of clinical trials assessing the efficacy of these agents in humans in such clinical scenarios. Hence, there are no guidelines or ideal agents to use in such a scenario. We do not recommend the use of FFP for bleeding related to NOACs. In the setting of early overdose of dabigatran (within 3-4 hours), activated charcoal may be given, and hemodialysis may be used if there is evidence of critical organ bleeding. In our opinion, 4-factor PCC or 3-factor PCC at a dose of about 50 U/kg may be given in an emergency setting to manage bleeding related to factor Xa inhibitors such as rivaroxaban or apixaban, but not direct thrombin inhibitors such as dabigatran. We are also of the opinion that aPCC (FEIBA®) would not be helpful for management of direct thrombin inhibitor (dabigatran)-related bleeding, based on current available efficacy data in humans. We reserve the use of Novoseven® as a last resort, given the lack of pre-clinical or clinical data supporting its ability to reverse the anticoagulant effects of NOACs, except in one case report where it was used in combination with hemodialysis.
  Current Treatment Options in Cardiovascular Medicine 03/2013;
• Article: Broken Heart Syndrome, Neurogenic Stunned Myocardium and Stroke.

  Amit S Dande, Amrita S Pandit
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  ABSTRACT: OPINION STATEMENT: The diagnosis of stress cardiomyopathy is often made during coronary angiography. At this point hemodynamic parameters should be assessed; a right heart catheterization with measurement of cardiac output by Fick and thermodilution methods is helpful. Patients with acute neurologic pathology who develop left ventricular dysfunction (neurogenic stunned myocardium) may not be candidates for coronary angiography and in such cases real-time myocardial contrast echocardiography or nuclear perfusion scan can be used to exclude obstructive coronary disease. Hypotension and shock can be due to low output state or left ventricular outflow tract obstruction. Low output state can be managed with diuretics and vasopressor support. Refractory shock and/or severe mitral regurgitation may require an intra-aortic balloon pump for temporary support. In patients with intraventricular gradient intravenous beta-blockers have been used safely. Hemodynamically unstable patients should be managed in a critical care unit and stable patients should be monitored on a telemetry unit as arrhythmias may occur. An echocardiogram should be performed to look for intraventricular gradient, mitral regurgitation, or left ventricular thrombus. If left ventricular thrombus is seen or suspected anticoagulation with warfarin or low molecular weight heparin is generally advised until recovery of myocardial function and resolution of thrombus occurs. In patients with subarachnoid hemorrhage the use of vasopressors to reduce cerebral vasospasm may worsen left ventricular outflow tract gradient. In hemodynamically stable patients, a beta-blocker or combined alpha/beta blocker should be initiated. Myocardial function generally recovers within days to weeks with supportive treatment in most patients. The use of a standard heart failure regimen including an angiotensin-converting enzyme inhibitor or aldosterone receptor antagonist, beta-blocker titrated to maximal dose, diuretics, and aspirin is common until complete recovery of myocardial function occurs. Chronic therapy with a beta-blocker may be advisable. The underlying diagnosis that precipitated stress cardiomyopathy such as critical illness, neurologic injury, or medication exposure should be identified and treated.
  Current Treatment Options in Cardiovascular Medicine 03/2013;
• Article: Therapeutic Options to Reduce Lp-PLA2 Levels and the Potential Impact on Vascular Risk Reduction.

  Koto Ishida, Brett Cucchiara
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  ABSTRACT: OPINION STATEMENT: Lipoprotein-associated phospholipase A2 (Lp-PLA2) is an enzyme involved in the metabolism of Low-density lipoprotein (LDL) to pro-inflammatory mediators. Lp-PLA2 is highly expressed in the necrotic core of atherosclerotic plaques and has been associated with atherosclerotic plaque instability. Multiple studies have shown an association between elevated Lp-PLA2 levels and risk of both stroke and myocardial infarction, even after adjustment for standard vascular risk factors, and several professional organizations have recommended Lp-PLA2 as a potentially usefully tool to improve risk stratification for individual patients. Therapies directed at lowering Lp-PLA2 levels may represent a novel approach to reducing vascular risk, though direct clinical benefit from targeting treatment to Lp-PLA2 levels remains unproven. Statins appear to significantly lower Lp-PLA2 levels; fibrates and niacin may also lower Lp-PLA2 levels, though this is less well established. Darapladib, a potent, selective Lp-PLA2 inhibitor, is currently in phase III trials for prevention of recurrent vascular events in patients with coronary artery disease.
  Current Treatment Options in Cardiovascular Medicine 03/2013;
• Article: Exercise Therapy for Claudication: Latest Advances.

  Ryan J Mays, Judith G Regensteiner
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  ABSTRACT: OPINION STATEMENT: Peripheral artery disease (PAD) creates a significant national and international healthcare burden. A first line treatment for PAD is supervised walking exercise in hospitals and clinics. Specifically, supervised walking exercise seeks to improve the classic symptom associated with PAD, intermittent claudication (IC), which is characterized by cramping, aching, and pain of the muscles in the lower extremities during walking. While effective, supervised walking exercise is often not prescribed or utilized due to a number of treatment barriers such as lack of transportation to clinical centers and lack of insurance reimbursement. Walking exercise in community settings is an option that has gained attention due to the limitations of supervised walking exercise, as community walking is generally more convenient in terms of a patient's schedule and may circumvent potential barriers such as treatment cost and transportation difficulties. However, more research is needed to improve the effectiveness of community-based walking programs since far less is known about the optimal structure of such programs. Other exercise therapy options are becoming available for PAD patients in addition to walking exercise. These modalities include but are not limited to leg and arm ergometry, polestriding and resistance training. These exercise therapy options have not to date been as well validated as supervised walking exercise. However, they may potentially be used in the event supervised walking exercise is not feasible or patient preference warrants an alternative exercise strategy.
  Current Treatment Options in Cardiovascular Medicine 02/2013;
• Article: Migraine, Stroke and Epilepsy: Underlying and Interrelated Causes, Diagnosis and Treatment.

  Aida Rodriguez-Sainz, Ana Pinedo-Brochado, Jose L Sánchez-Menoyo, Javier Ruiz-Ojeda, Ines Escalza-Cortina, Juan Carlos Garcia-Monco
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  ABSTRACT: OPINION STATEMENT: Migraine, epilepsy and stroke are highly prevalent neurological disorders, often comorbid. They share diverse pathophysiological mechanisms that explain the use of similar drugs on certain occasions (i.e., the use of antiepileptic drugs in migraine prevention). Migraine with aura represents a risk for ischemic stroke, and avoiding contraceptives, tobacco use, and ergot alkaloids should be advised in those patients. Epilepsy bears a bidirectional relationship with headache. Only three entities are considered as seizure-related headaches: migraine-triggered seizure (migralepsy), hemicrania epileptica, and post-ictal headache. Topiramate (100-200 mg daily) and valproic acid (500-1,000 mg daily) are first-line drugs in migraine prevention, while older antiepileptics have no use in this setting. Stroke is the most common cause of symptomatic epilepsy in the adult. Therapy with lamotrigine, gabapentine, and levetiracetam is advised in late-onset (2 weeks after stroke) stroke-seizures, while early-onset seizures usually do not require therapy.
  Current Treatment Options in Cardiovascular Medicine 02/2013;
• Article: Atrial Fibrillation and Stroke: The Evolving Role of Rhythm Control.

  Taral K Patel, Rod S Passman
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  ABSTRACT: OPINION STATEMENT: Atrial fibrillation (AF) remains a major risk factor for stroke. Unfortunately, clinical trials have failed to demonstrate that a strategy of rhythm control--therapy to maintain normal sinus rhythm (NSR)--reduces stroke risk. The apparent lack of benefit of rhythm control likely reflects the difficulty in maintaining NSR using currently available therapies. However, there are signals from several trials that the presence of NSR is indeed beneficial and associated with better outcomes related to stroke and mortality. Most electrophysiologists feel that as rhythm control strategies continue to improve, the crucial link between rhythm control and stroke reduction will finally be demonstrated. Therefore, AF specialists tend to be aggressive in their attempts to maintain NSR, especially in patients who have symptomatic AF. A step-wise approach from antiarrhythmic drugs to catheter ablation to cardiac surgery is generally used. In select patients, catheter ablation or cardiac surgery may supersede antiarrhythmic drugs. The choice depends on the type of AF, concurrent heart disease, drug toxicity profiles, procedural risks, and patient preferences. Regardless of strategy, given the limited effectiveness of currently available rhythm control therapies, oral anticoagulation is still recommended for stroke prophylaxis in AF patients with other stroke risk factors. Major challenges in atrial fibrillation management include selecting patients most likely to benefit from rhythm control, choosing specific antiarrhythmic drugs or procedures to achieve rhythm control, long-term monitoring to gauge the efficacy of rhythm control, and determining which (if any) patients may safely discontinue anticoagulation if long-term NSR is achieved.
  Current Treatment Options in Cardiovascular Medicine 02/2013;
• Article: IgG4-related Disease: 2013 Update.

  Paul A Monach
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  ABSTRACT: OPINION STATEMENT: Having diagnosed a patient as having IgG4-related disease, I would have a low threshold for recommending immune-suppressive treatment, and would make that recommendation for any patient with vascular involvement. My initial approach would be prednisone at 40-60 mg/day with a plan to reduce the dose every two weeks, e.g., 40, 30, 20, 15, 10, 7.5, 5, and 2.5 mg for 2 weeks each. In the event of relapse, I would double the current prednisone dose, slow the taper, and add azathioprine, anticipating using that drug for one year if the patient were to remain in remission. In the event or subsequent relapse, I would stop azathioprine and use rituximab. In a patient with large artery involvement, I would consult a vascular surgeon soon after diagnosis, anticipating a need for surgical repair.
  Current Treatment Options in Cardiovascular Medicine 02/2013;
• Article: Novel Anticoagulant Use for Venous Thromboembolism: A 2013 Update.

  Alejandro Perez, Geno J Merli
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  ABSTRACT: OPINION STATEMENT: Many pharmacologic options are available for prevention and treatment of venous thromboembolism (VTE). The anticoagulant selected may vary according the individual patient situation such as the acute versus chronic setting, renal function and indication for either VTE prevention or treatment. Established methods of pharmacologic prophylaxis agents include heparinoids, injectable anti-Xa inhibition and vitamin K antagonists (VKA). The novel anticoagulants have recently been incorporated into orthopedic surgery prophylaxis pathways and can be used for VTE treatment. Chronic VTE management, however, has largely been managed with the use VKA. The advantages of VKA include low cost, familiarity with use, and established protocols to manage catastrophic bleeding. VKA use, however, poses hurdles including the fact that correct dosing can be empiric, the existence of multiple potential medication and dietary interactions, and the possiblity for complications when anticoagulation levels are not well monitored. In contrast, the novel anticoagulants offer ease of dosing, reliable pharmacokinetics and low risk of interactions with other medications or diet. Potential hazards of the novel anticoagulants include high costs, questionable therapeutic benefit in those with poor adherence, a reliance on renal clearance, lack of reliable reversibility in the event of catastrophic bleeding, as well as incomplete familiarity with use by the general practitioner. Although clinical trials demonstrate promise of greater applicability of use of these novel agents, hospital systems will need to simultaneously create a plan for appropriate management of the use of these agents, an anticoagulation stewardship program. As guidelines are adopted to prevent and manage VTE, an appreciation for this new level of complexity is essential.
  Current Treatment Options in Cardiovascular Medicine 02/2013;
• Article: Diagnosis and Management of Vertebrobasilar Insufficiency.

  Aaron Stayman, Raul G Nogueira, Rishi Gupta
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  ABSTRACT: OPINION STATEMENT: Understanding the anatomical pathways and clinical presentations for VBI are of the utmost importance due to the potential mimics that may occur. After identification of the entity, imaging must be performed to identify the etiology. Distinguishing external compression of the vertebral artery from intrinsic vascular disease due to atherosclerosis or dissection is critical to aid the clinician in the therapeutic decision tree. Patients with an external compression due to an osteophyte may benefit from definitive surgical decompression and excision of the bony structure. Patients with extracranial disease of the vertebral artery who have failed maximal medical therapy may benefit from angioplasty and stenting which appears to carry a low morbidity. Extracranial vertebral artery dissections can be treated with medical therapy using anti-platelet agents or on occasion anti-coagulation. Rarely, endovascular options are required if a patient is having hemodynamic stroke or TIAs due to flow failure. In such circumstances, stenting and angioplasty may be considered. Intracranial atherosclerosis is best managed with maximal medical therapy due to the high rate of complications attributable to stenting and angioplasty.
  Current Treatment Options in Cardiovascular Medicine 02/2013;