Peripheral vascular disease, treatment

Peripheral vascular disease Treatment with -antagonists reduces cardiac output and can precipitate or aggravate the symptoms of arterial insufficiency in patients with peripheral or mesenteric vascular disease. 

Nitroglycerin remains the dmg of choice for treatment of angina pectoris. It has also been found useful for the treatment of congestive heart failure, myocardial infarction, peripheral vascular disease, such as Raynaud s disease, and mitral insufficiency, although the benefits of nitroglycerin in mitral insufficiency have been questioned. 

Nifedipine (Table 3) is a potent vasodilator that selectively dilates resistance vessels and has fewer effects on venous vessels. It does not cause reflex tachycardia during chronic therapy. Nifedipine is one of the first-line choices for black or elderly patients and patients having concomitant angina pectoris, diabetes, or peripheral vascular diseases. Nifedipine, sublingually, is also suitable for the treatment of hypertensive emergencies. Nifedipine does not impair sexual function or worsen blood Hpid profile. The side effects are flushing, headache, and dizziness. 

Peripheral vasodilating drugs are chiefly used in the treatment of peripheral vascular diseases, such as arteriosclerosis obliterans, Raynaud s phenomenon, and spastic peripheral vascular disorders. Short-term use is rarely beneficial or permanent. Improvement, if it occurs, takes place gradually during weeks of therapy. 

Another drug that has been found to have anticytokine activity is pentoxifylline. It was initially characterized as a haemorheologic agent for the treatment of peripheral vascular diseases [141]. In addition, it was also found to be capable of inhibiting the pro-inflammatory actions of IL-1 and TNEa on neutrophil function and cytokine production by monocytic cells [142]. Its mechanism of action is the inhibition of phosphodiesterases, leading to increased intracellular levels of cyclic adenosine monophosphate [143]. Besides its effects on the cytokine network, pentoxifylline also exerted an anti-fibrogenic action in cultures of fibroblasts and in animal models of fibrosis [144] and could therefore be an attractive candidate for targeting hepatic inflammation. 

Older patients have predominantly Type 2 diabetes mellitus, which shares with Type 1 the risk for retinopathy, nephropathy and neuropathy, but carries a greater risk for macrovascular complications such as coronary artery disease, stroke and peripheral vascular disease. Many such patients have associated obesity, hypertension and hyperlipidemia, compounding the risk of cardiovascular disease. The goals of treatment of DM in the elderly are to decrease symptoms related to hyperglycaemia and to prevent long-term complications. Treatment of type 2 DM can improve prognosis. In the UKPDS trial, sulphonylureas, insulin, and metformin were all associated with a reduction in diabetes-related... 

Exercise is an essential yet neglected aspect of treatment for type 2 diabetes especially in its early stages where insulin resistance may predominate. Accumulation of at least 30 0 minutes of moderate physical activity on most days of the week is recommended. For type 1 diabetes the emphasis must be on adjusting the therapeutic regimen to allow safe sports participation to prevent precipitation of ketoacidosis or hypoglycaemia. Extra care is required in cases with known complications like proliferative retinopathy, nephropathy, foot ulcers and cardiac or peripheral vascular disease. 

Isoxsuprine has been used to arrest premature labor, where it is given in a loading dose of 0.2-1 mg/min for 10 minutes and then reduced to 0.1-0.3 mg/min [40, 41], It has been also used in the treatment of cerebral and peripheral vascular diseases [42], intermittent claudication [43], and obliterative arterial diseases [44]. 

Isoxsuprine has a potent inhibitory effect on vascular and uterine smooth muscle and has been used in the treatment of dysmenorrhoea, threatened abortion, premature labour and peripheral vascular diseases. Adverse effects include nausea, tachycardia, flushing and dizziness. 

Salicylism and death have occurred following topical application. In an adult, 1 g of a topically applied 6% salicylic acid preparation will raise the serum salicylate level not more than 0.5 mg/dL of plasma the threshold for toxicity is 30-50 mg/dL. Higher serum levels are possible in children, who are therefore at a greater risk for salicylism. In cases of severe intoxication, hemodialysis is the treatment of choice (see Chapter 58). It is advisable to limit both the total amount of salicylic acid applied and the frequency of application. Urticarial, anaphylactic, and erythema multiforme reactions may occur in patients who are allergic to salicylates. Topical use may be associated with local irritation, acute inflammation, and even ulceration with the use of high concentrations of salicylic acid. Particular care must be exercised when using the drug on the extremities of patients with diabetes or peripheral vascular disease. 

These elfects on cerebrovascular events and on intermittent claudication suggest that simvastatin and other elfective lipid-lowering treatments may have a general antiatherosclerotic elfect not limited to the coronary bed. Definitive evidence on the elfects of statin therapy in stroke prevention and peripheral vessel disease is likely to be provided by the Heart Protection Study (MRC/BHF Heart Protection Study Collaborative Group, 1999). As noted above, this UK study has randomized over 20,000 patients aged up to 80 to simvastatin 40 mg or placebo, and the 5-year treatment period is scheduled for completion in 2001. Among these patients are 3288 patients with a history of cerebrovascular disease. Because of its size and the broad array of patient types randomized, this study should also provide reliable evidence of the elfect of simvastatin on coronary morbidity and mortality in women, elderly patients, patients with low levels of LDL and HDL cholesterol, patients with peripheral vascular disease, and diabetic patients with or without coronary disease (MRC/BHF Heart Protection Study Collaborative Group, 1999). 

Calcium channel blockers have an intrinsic natriuretic effect therefore, they do not usually require the addition of a diuretic. These agents are useful in the treatment of hypertensive patients who also have asthma, diabetes, angina, and/or peripheral vascular disease. 

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