Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. This slide presentation covers basic science and clinical advances in treatment of erectile dysfunction, with emphasis on the cardiovascular patient. The editorial content of this program does not necessarily reflect the views or recommendations of the University of Florida College of Medicine, Pfizer Inc, or the publisher. This program was prepared and produced by Medical Education Consultants Inc, Westport, Connecticut, on behalf of the University of Florida College of Medicine through an unrestricted educational grant provided by Pfizer Inc.
The VBWG Core Curriculum 2002 slide lecture program, Impact of vascular biology in treatment of cardiovascular disease, covers basic science and clinical advances in vascular biology in a spectrum of disorders.
Symptoms of Ischemic Heart Disease Chest discomfort with variable characteristics -pain, pressure, tightness, crushing, squeezing, stabbing, choking sensations. Patient Education for Early Recognition and Response to Chest Pain Healthcare providers should instruct patients previously prescribed nitroglycerin (NTG) on use for chest discomfort or pain and to call 9-1-1 if symptoms do not improve or worsen 5 minutes after ONE sublingual NTG dose*. Prehospital Chest Pain Evaluation and Treatment Prehospital EMS providers should administer 162 to 325 mg of aspirin (chewed) to chest pain patients suspected of having STEMI unless contraindicated or already taken by the patient. Options for Transport of Patients With STEMI and Initial Reperfusion Treatment EMS Transport Onset of symptoms of STEMI 9-1-1 EMS Dispatch EMS on-scene Encourage 12-lead ECGs. 012345678012345678012345678012345678 Cardiac troponin-no reperfusion Days After Onset of STEMI Multiples of the URL Upper reference limit 1 2 5 10 20 50 URL = 99th %tile of Reference Control Group 100 Cardiac troponin-reperfusion CKMB-no reperfusion CKMB-reperfusion Cardiac Biomarkers in ACS Alpert et al. Troponin I Levels and Mortality in Patients with NSTEMI 0 2 4 6 8 0- 9.0 % Mortality at 42 Days Adapted with permission from Antman EA, Tanasijevic MJ, Thompson B, et al.
EKG Changes in STEMI ST elevation of 1mm or more in the limb leads or of 2mm or more in precordial leads is significant.
Non-invasive Diagnostic Testing Echocardiography Exercise stress testing Pharmacologic stress testing -Adenosine -Persantine Nuclear stress testing Echocardiography CTA Cardiac MRI May be considered only after acute MI or other emergent process has been ruled out. Patients with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous NTG. Analgesia Morphine sulfate (2 to 4 mg intravenously with increments of 2 to 8 mg intravenously repeated at 5 to 15 minute intervals) is the analgesic of choice for management of pain associated with STEMI. Aspirin Aspirin should be chewed by patients who have not taken aspirin before presentation with STEMI.
NSAIDs NSAIDS (except ASA) should not be given during the acute hospitalization due to increased risk of mortality, reinfarction, HTN, heart failure, and myocardial rupture. Oral beta-blocker therapy should be administered promptly to those patients without a contraindication, irrespective of concomitant fibrinolytic therapy or performance of primary PCI.

Efficacy of Pycnogenol in patients with venous insufficiency has been proven in eight double-blind studies with approx.
Forty patients with chronic venous insufficiency were treated with 3 X 100 mg Pycnogenol per day or placebo for two months.
As soon as at the end of the first month many patients in the Pycnogenol group became asymptomatic. The aim of this study was to compare the efficacy of Venostasin (horse chestnut seed extract) and Pycnogenol (French maritime pine bark extract) in the treatment of chronic venous insufficiency (CVI).
Italian researchers ( L'Aquila University) compared the efficacy of daily 150 mg or 300 mg Pycnogenol vs.
After e ight weeks of treatment ankle swelling decreased by 35% in the Pycnogenol group and 19% of the diosmin -hesperidine group. In addition, Pycnogenol significantly increased oxygen, and decreased the carbon dioxide concentration in the skin of the leg, thus improving blood flow to the leg. The higher dose of Pycnogenol (300 mg) did not have not significantly better effects than the lower dose (150 mg), except for the total symptom score values. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric- coated formulations.
Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. The pattern of ST elevation indicates the location of infarct and the involved coronary artery.
Intravenous NTG is indicated for relief of ongoing ischemic discomfort that responds to nitrate therapy, control of hypertension, or management of pulmonary congestion.
It is reasonable to administer intravenous beta- blockers promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present. The increase in leg volume was measured by means of water displacement in supine and sedentary position (for 2 hours). The subjective symptoms of venous insufficiency (heavy legs, swelling, pain) were studied using a standard questionnaire. At the end of the second month, the majority of patients became free of pain and swelling, and the tolerability was excellent. In an randomized, controlled study 40 patients with diagnosed chronic venous insufficiency (CVI) were treated either with 600 mg chestnut seed extract per day or 360 mg Pycnogenol per day over a period of 4 weeks. 1000 mg diosmin -hesperidine combination (Daflon, Detralex) administered for eight weeks, to 86 patients with with severe chronic venous insufficiency, venous hypertension, and ankle swelling.

The decrease in the symptom score (pain, restless legs, tired legs, skin lesions) was 64% in the Pycnogenol group, and half of that, 32% in the diosmin -hesperidine group. The diosmin -hesperidine did not affect significantly tissue oxygenation, therefore did not improve the blood circulation in the legs.
Venous ulcers: microcirculatory improvement and faster healing with local use of Pycnogenol.
It is reasonable for all 9-1-1 dispatchers to advise patients without a history of aspirin allergy who have symptoms of STEMI to chew aspirin (162 to 325 mg) while awaiting arrival of prehospital EMS providers. In addition to the measurement of ankle swelling, questionnaires were used to determine the score of the subjective symptoms (pain, restless legs, redness of the skin).
Pycnogenol improved oxygen concentrations five times, and decreased carbon dioxide concentration 15 times better, than diosmin -hesperidine. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations.
EMS Triage Plan Inter- Hospital Transfer PatientEMSPrehospital fibrinolysis EMS-to-needle within 30 min.
The four-day Pycnogenol treatment significantly reduced the increase in leg volume in sedentary position.
In addition, blood levels of cholesterol LDL and HDL were determined before and at the end of treatment. Pycnogenol significantly reduced the circumference of the lower limbs and significantly improved subjective symptoms. Furthermore, Pycnogenol significantly decreased cholesterol and LDL values in the blood, whereas HDL remained unaffected. Venostasin only moderately but not significantly, reduced the circumference of the lower limbs and marginally improved symptoms. In conclusion, Pycnogenol was found to be more efficacious than Venostasin for the treatment of CVI.

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