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New insights in pharmacotherapy of peripheral circulation

ESC Congress Report

  • Anti-platelet agents: drugs for all patients with peripheral artery disease?
  • β-blockers: friend or foes ?
  • Statin: a therapy for every patient with peripheral atherosclerosis?
  • The diabetic patients: a separate entity with peculiar features?

View the Slides from this session in ESC Congress 365

The aim of the session was to cover new scientific evidence and therapeutic perspectives related to peripheral vascular disease, and in general, to vascular protection.

Prof. John Lekakis from (Athens, Greece) addressed the role of antiplatelet treatment, reviewing the different drug classes, as well as the available intervention data, including recent meta-analyses. Clinical data suggest the usefulness of therapeutic intervention with aspirin or clopidogrel in patients with coronary artery disease of lower extremity artery disease; while data concerning other localizations of peripheral vascular disease, including carotid arteriosclerosis, are rather limited. However, also considering that very frequently localizations of vascular disease are simultaneously present in different vascular districts, ESC Guidelines on the diagnosis and treatment of peripheral artery diseases (Eur Heart J 2011; 32:2851-2906) suggest using antiplatelet agents in every patient with peripheral vascular disease, irrespective of the presence or not of clinical symptoms.

The use of β-blockers in patients with clinical evidence of peripheral vascular disease represents a controversial issue. Prof. Christine Espinola-Klein (Mainz Germany) reviewed available data concerning this issue. β-blocking drugs, especially first and second generation compounds, may have a vasoconstrictor effect, thus possibly reducing walking distance in patients with peripheral artery disease.
However, the protective action in patients with coronary artery disease is rather indisputable.  Available clinical data with older drugs are controversial, showing either no effect, or sometimes a worsening effect on walking distance. Newer beta blockers (nebivolol, carvedilol) with additional vasodilating properties seem to have positive effects in this regard, increasing walking distance.
Also, data concerning the effects of β-blockers on morbidity and mortality in patients undergoing vascular surgery are controversial (3 trials showing a benefit, 1 showing increased mortality). ESC Guidelines on non-cardiac surgery (Eur Heart J. 2014 Aug 7) suggest that, in patients with peripheral vascular disease,  β-blockers should be continued, and, in some cases (high risk patients), initiated ex novo.

Prof. Dimitrios Richter (Athens, Greece) reviewed available data concerning the clinical use of statins in patients with peripheral artery disease, showing convincing data in favour of their extensive use in nearly every patient with a localization of vascular disease.

Finally, Prof. Emmanuel Messas (Paris, France) answered the question of whether the diabetic patients should be considered a separate entity.
Diabetic patients have severe and widespread vascular lesions. They are at particularly high cardiovascular risk; mechanisms possibly involved include insulin resistance, changes in downstream insulin signalling, microRNA, microparticles, increased thrombosis and coagulation and platelet hyperactivity.
The speaker also addressed tthe hypothesis of the presence of a vascular hyperglycaemic memory, since the hyperglycaemic environment may be remembered by the vasculature. Oxidative stress is among the mechanisms possibly involved in this process. Therefore, treatment targets include lipids, glucose levels, blood pressure and thrombosis. Non-pharmacological treatment may be important as well.

The different presentations of the session were well-integrated and balanced, and clinical applications and translational evidence were adequately highlighted.
In general, the session provided an updated overview of the current “state of art” concerning the role of drug treatment in vascular protection of patients with peripheral artery disease, particularly focusing on anti-platelet drugs, statins, β-blockers and on risk stratification of patients that represent a relevant proportion of those seen in clinical practice.




New insights in pharmacotherapy of peripheral circulation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.