From the Guidelines
The next step for this 68-year-old female with transient monocular vision loss, negative MRI, new-onset hypertension, and possible fibromuscular dysplasia (FMD) should be a comprehensive vascular imaging evaluation, including carotid and cerebral angiography or CTA/MRA of the head and neck, to evaluate for the characteristic "string of beads" appearance of FMD in the carotid and vertebral arteries, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1.
Given the patient's symptoms and the ophthalmologist's suspicion of FMD, it is crucial to confirm the diagnosis and assess the extent of disease. The guideline suggests that annual noninvasive imaging of the carotid arteries is reasonable initially for patients with FMD to detect changes in the extent or severity of disease, although the effect on outcomes is unclear 1.
Key considerations in the management of this patient include:
- Continuing the current antiplatelet therapy (Plavix and aspirin) and statin (rosuvastatin) to prevent thromboembolism, as administration of platelet-inhibitor medication can be beneficial in patients with FMD of the carotid arteries 1
- Initiating or optimizing antihypertensive therapy to target a blood pressure below 140/90 mmHg, given the new-onset hypertension
- Referring the patient to a vascular specialist with experience in FMD for long-term management, as FMD is an uncommon non-atherosclerotic, non-inflammatory vascular disease that can cause arterial stenosis, aneurysm, and dissection, leading to ischemic symptoms like transient monocular vision loss
- Considering renal artery imaging to assess for renal artery involvement, which may explain the new-onset hypertension, as FMD can affect multiple vascular beds.
It is essential to prioritize the patient's morbidity, mortality, and quality of life in the management of FMD, and the recommended comprehensive vascular imaging evaluation and ongoing medical therapy aim to achieve these outcomes.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Next Steps in Diagnosis and Management
Given the patient's symptoms and the ophthalmologist's suspicion of fibromuscular dysplasia (FMD), the next steps should focus on confirming the diagnosis and managing the condition appropriately.
- Imaging Studies: Panvascular imaging from head-to-pelvis may be considered for screening purposes, as FMD can affect any arterial bed and lead to various morbid conditions 2.
- Medication Management: The patient is already on Plavix, aspirin, and rosuvastatin as part of the stroke protocol. However, the use of anti-platelet agents in FMD patients, especially those with cerebrovascular involvement, is common 3. The management of hypertension is also crucial, given the patient's new onset HTN and the association of FMD with renovascular hypertension.
- Specialist Referral: A multispecialty team approach is recommended for the optimal treatment of FMD, considering its potential to affect multiple arterial beds and the variety of clinical manifestations 2, 4.
- Procedure Considerations: If intervention is necessary, endovascular intervention with angioplasty alone is often the preferred modality, though surgical intervention may be required in some cases 2. Pre-procedural patient preparation and post-procedural care are critical components of management 5.
Considerations for FMD Diagnosis
- Differential Diagnosis: The differential diagnosis of FMD is extensive and includes imaging artifacts as well as other arterial diseases. Diagnosis is based on CT-, MR-, or conventional catheter-based angiography during the work-up of clinical manifestations 4.
- Registry and Research: Participation in registries like the United States Registry for Fibromuscular Dysplasia or the European/International FMD Registry can provide valuable insights into the disease's clinical manifestations, epidemiology, natural history, and pathogenesis 3, 6.