ESVM guidelines – the diagnosis and management of Raynaud’s phenomenon

Abstract. Regarding the clinical diagnosis of Raynaud’s phenomenon and its associated conditions, investigations and treatment are substantial, and yet no international consensus has been published regarding the medical management of patients presenting with this condition. Most knowledge on this topic derives from epidemiological surveys and observational studies; few randomized studies are available, almost all relating to drug treatment, and thus these guidelines were developed as an expert consensus document to aid in the diagnosis and management of Raynaud’s phenomenon. This consensus document starts with a clarification about the definition and terminology of Raynaud’s phenomenon and covers the differential and aetiological diagnoses as well as the symptomatic treatment.

"No more amputations": a complex scientific problem and a challenge for effective preventive strategy implementation on vascular field

Lower limb vascular amputations represent serious problem in the vascular care. As a consequence of critical limb ischemia, often associated with diabetes, it is highly critical to health care service aiming at prevention of limb loss. Understanding of the nature and complexity of amputation scenario is paramount for the effective preventive strategy planning and implementation. Amputation incidence and data of the trends show high variability in the international reports. Variability is also remarkable in a more granular, regional comparison. Different calculation methods for incidence fraction, varying epidemiological, demographic features of the populations, different socio-economic, cultural backgrounds and disparity in vascular care are the main factors contributing to this variability in reports. Lower limb amputations can be considered as a valuable healthcare quality indicator with some limitations. One of these limitations is the lower actionability that corresponds to the reduced ability of health care providers to intervene influencing the burden of amputations. Lower limb vascular amputations represent a lifetime risk, therefore not only the effective revascularization is to be achieved but the importance of the early recognition of peripheral arterial disease, no delay in referral to special vascular care, effective vascular risk prevention and collaboration in multidisciplinary teams should be also emphasized.

[Quality of life and burden of disease in peripheral arterial disease: a study among Hungarian patients]

INTRODUCTION

Peripheral arterial disease may occur in about of 14% of patients with high blood pressure, of which 1-3% suffer from chronic critical limb ischemia. Literature data on the quality of life according to the Fontaine stages are very limited.

AIM

The aim of this study was to assess the quality of life of Hungarian patients with peripheral arterial disease regarding Fontaine stages II, III and IV.

METHODS

The study was based on a cross-sectional survey, which was carried out in four angiologic centres. One hundred and two respondents with peripheral arterial disease (43% woman) were evaluated. The average age of the patients was 70 years (SD-10).

RESULTS

Based on the EQ-5D index, the results of the quality of life assessment with respect to Fontaine stages II, III and IV were 0.66, 0.35 and 0.18, respectively. In each stage the EQ-5D values were lower than the values of the age-matched average population. The results of the Pain Visual Analogue Scale (0-100 mm) were 38, 65 and 71 mm in Fontaine stages II, III and IV, respectively, and this showed a strong correlation with the EQ-5D (R = -0.68). In stage Fontaine IV the quality of life of the patients was significantly lower among those who had pain at rest and ALSO ulcer on the leg.

CONCLUSIONS

Peripheral disease with clinical symptoms causes significant reduction in quality of life which can be measured with EQ-5D. It becomes worse as we move along the Fontaine stages. While measuring the health gain in stage Fontaine IV, the health gain from the reduction of pain in rest and partial recovery from ulcer should be taken into account.

[Effectiveness of prostanoids in patients with critical leg ischemia]

Prostanoids (alprostadil and iloprost) are used for the treatment of patients with critical limb ischemia in whom revascularization procedure is inadequate or proved to be unsuccessful. According to a Cochrane analysis (CD006544) prostanoids differ in their effects on rest-pain relief and ulcer healing.

OBJECTIVES

To study the efficacy and safety of prostanoids for critical limb ischemia.

METHODS

Systematic literature search and meta-analysis (mixed treatment comparison) was performed.

RESULTS

Seven randomized controlled trials including 964 patients were analyzed. Compared to placebo, both alprostadil (OR: 3.2 95% CI: 1.7-5.5 and OR: 1.8 95% CI: 0.6-4.3) and iloprost (OR: 2.7 95% CI: 1.7-4.2 and OR: 2.5 95% CI: 1.0-5.4) were more efficacious with regard to rest-pain relief and ulcer healing and the difference between the two prostanoids was not significant (OR: 1.2 95% CI: 0.7-1.9 and OR: 0.74 95% CI: 0.3-1.5). Adverse events occurred significantly more often with both drugs compared to placebo, however, they were less frequent with alprostadil than with iloprost (OR 0.2 95% CI: 0.1-0.3).

CONCLUSIONS

Prostanoids have favorable effect on rest-pain relief and ulcer healing in critical limb ischemia, without statistically significant difference between the two available drugs. The Cochrane study (CD006544) reported mistaken results due to defaults in the analysis.

[Dobutamine stress cardiovascular magnetic resonance imaging in patients with peripheral artery disease]

Patients with peripheral arterial disease often have coronary heart disease, as well. However, their assessment with classical noninvasive cardiology methods is often non-diagnostic or limited. The aim of this study was to analyze the feasibility and the risks of dobutamine stress cardiovascular MRI for cardiac evaluation of patients with peripheral arterial disease. 21 patients with peripheral artery disease (mean±SD age 64.3±7.7 years) were studied prospectively with dobutamine stress cardiovascular MRI. The protocol was completed by all of 21 patients. The target heart rate was attained in 95.2% of the studies. No serious adverse event occurred. The image quality scores (1-4) for all ventricular wall segments were high (median, interquartile range) (4 [4-4]). Five patients (23.8%) have inducible wall motion abnormality. Interobserver agreement was almost perfect for wall motion scores (κ = 0.87, p<0.0001). Dobutamine stress cardiovascular MRI is feasible with low risk for the cardiological assessment of patients with peripheral arterial disease.