Medical Management of Peripheral Vascular Disease Flashcards
Aims of Medical Management of PVD
Relieve Symptoms
Improve walking distance/QOL
Limit progression of the disease
Risk Factors for PVD
Age
Smoking
Diabetes
HIgh BP, Cholesterol and homocyteine
Treatments of PVD
Risk factor modification
Drug therapies (anti-platelets, etc)
Surgery
Smoking Cessation
Slow progression of disease/progression to CLI
Reduces risk of death from other cardiovascular causes
Does not improve walking distance/claudication.
Treating High cholesterol
Statins reduce serum cholesterol and improve endothelial function
Reduces risk of death from other cardiovascular causes
No direct effect on PVD
Diabetic control
Prevents microvascular complications (nephropathy, retinopathy, neuropathy)
Not clear if effective on Macrovascular complications
Does not affect amputation risk
Treating Hypertension
Not clear if effective at slowing disease progression.
Effective at preventing strokes/ other cardiovascular death
Calcium Channel Blockers in PVD
Act as vasodilators
May increase flow by decreasing small vessel resistance
Can reduce systemic blood pressure reducing flow to limb
Proven to help in Raynaud’s
Not clear if helpful in PVD
Reducing homocysteine levels
Can use B vits and folate to reduce serum homocysteine
But no evidence it has any effect in coronary or PVD patients.
Anti-platelet Therapy
V effective at reducing cardiovascular/ischemic deaths
maintains graft patency and reduces thrombotic complications of PVD
Exercise Therapy
Improves functional capacity by development of collaterals
Gives comparable benefit to bypass surgery
Requires motivation and supervision
Exercise therapy is best if
sessions > 30 mins
>3 sessions a week
>6 months of sessions
Benefits start after four weeks
Anti-platelet agents used in PVD
Asprin routinely given
Clopidegrel given instead if allergic to aspirin
Both given if high risk
Use of Anti-hypertensive Agents in PVD
Vasodilating B-blocker (nebivolol, carvedilol) ok in moderate but not severe disease
ACEi/ARBs must be used cautiously due to risk of renal disease in PVD patients
Drug Rx of Claudication: Cilostazol
PDE3 inhibitor - anti-platelet, vasodilator, inhibits VSMC proliferation
Small increase in ABI and HDL
Found to improve walking distance/QOL indicators
Problems with Cilstazol
Side effects- headache, diarrhoea, palpitations, dizziness
Contraindicated in heart failure
Not currently endorsed by NICE
Drug Rx of Claudication: Naftidrofuryl
5HT2 receptor blocker
Improves painfree but not max walking distance
NICE endorses its use in appropriate patients
Drug Rx of Claudication: Levocarnitine
May improve metabolism and performance in ischemic skeletal muscle
Possible positive effect on walking distance and QOL
Not currently licensed
Drug Rx of Claudication: Prostaglandins
PGE1/beraprost (synthetic analogue) improve walking distance/QOL
Mainly studied for treating CLI
Can cause headache, flushing and GI side-effects
Claudication
Leg pain on exertion due to insufficient oxygen supply - Occurs in 15-40% of PVD patients
Critical Leg Ischemia
Ischemic pain at rest due to terminal lack of supply to leg - mortality 25%
Risk Factors for PVD
Age
Smoking
Diabetes
HIgh BP, Cholesterol and homocyteine
Treatments of PVD
Risk factor modification
Drug therapies (anti-platelets, etc)
Surgery
Smoking Cessation
Slow progression of disease/progression to CLI
Reduces risk of death from other cardiovascular causes
Does not improve walking distance/claudication.
Treating High cholesterol
Statins reduce serum cholesterol and improve endothelial function
Reduces risk of death from other cardiovascular causes
No direct effect on PVD
Diabetic control
Prevents microvascular complications (nephropathy, retinopathy, neuropathy)
Not clear if effective on Macrovascular complications
Does not affect amputation risk
Treating Hypertension
Not clear if effective at slowing disease progression.
Effective at preventing strokes/ other cardiovascular death
Calcium Channel Blockers in PVD
Act as vasodilators
May increase flow by decreasing small vessel resistance
Can reduce systemic blood pressure reducing flow to limb
Proven to help in Raynaud’s
Not clear if helpful in PVD
Reducing homocysteine levels
Can use B vits and folate to reduce serum homocysteine
But no evidence it has any effect in coronary or PVD patients.
Anti-platelet Therapy
V effective at reducing cardiovascular/ischemic deaths
maintains graft patency and reduces thrombotic complications of PVD
Exercise Therapy
Improves functional capacity by development of collaterals
Gives comparable benefit to bypass surgery
Requires motivation and supervision
Exercise therapy is best if
sessions > 30 mins
>3 sessions a week
>6 months of sessions
Benefits start after four weeks
Anti-platelet agents used in PVD
Asprin routinely given
Clopidegrel given instead if allergic to aspirin
Both given if high risk
Use of Anti-hypertensive Agents in PVD
Vasodilating B-blocker (nebivolol, carvedilol) ok in moderate but not severe disease
ACEi/ARBs must be used cautiously due to risk of renal disease in PVD patients
Drug Rx of Claudication: Cilostazol
PDE3 inhibitor - anti-platelet, vasodilator, inhibits VSMC proliferation
Small increase in ABI and HDL
Found to improve walking distance/QOL indicators
Problems with Cilstazol
Side effects- headache, diarrhoea, palpitations, dizziness
Contraindicated in heart failure
Not currently endorsed by NICE
Drug Rx of Claudication: Naftidrofuryl
5HT2 receptor blocker
Improves painfree but not max walking distance
NICE endorses its use in appropriate patients
Drug Rx of Claudication: Levocarnitine
May improve metabolism and performance in ischemic skeletal muscle
Possible positive effect on walking distance and QOL
Not currently licensed
Drug Rx of Claudication: Prostaglandins
PGE1/beraprost (synthetic analogue) improve walking distance/QOL
Mainly studied for treating CLI
Can cause headache, flushing and GI side-effects
Blood profile monitoring in statins
Lipid screen: before, 12 weeks after start, every year after
LFTs: as lipids (look out for ASTs)
CK: before therapy, repeat if muscle pain
Site of action of LWMH
Activates antithrombin III
Inhibits factor Xa
