What medications are used to manage vascular health?

Medications for Vascular Health Management

The primary medications used to manage vascular health include ACE inhibitors, ARBs, calcium channel blockers, thiazide diuretics, statins, antiplatelet agents, and beta-blockers, with selection based on specific vascular conditions and comorbidities. 1

Antihypertensive Medications

First-Line Options

• ACE inhibitors (Angiotensin-Converting Enzyme inhibitors) - reduce blood pressure, protect kidney function, and improve endothelial function; particularly beneficial for patients with diabetes, chronic kidney disease, or established coronary artery disease 1
• ARBs (Angiotensin Receptor Blockers) - alternative to ACE inhibitors with similar benefits but different side effect profile; preferred in patients who develop cough with ACE inhibitors 1
• Dihydropyridine calcium channel blockers (e.g., amlodipine) - effective for blood pressure control and particularly useful for vasospastic angina 1, 2
• Thiazide and thiazide-like diuretics (e.g., chlorthalidone, indapamide) - reduce blood pressure and cardiovascular events; preferred over hydrochlorothiazide due to longer duration of action 1

Second-Line and Specific Indication Medications

• Beta-blockers - recommended primarily for patients with specific indications such as angina, post-myocardial infarction, heart failure, or for heart rate control 1
• Mineralocorticoid receptor antagonists (e.g., spironolactone) - effective for resistant hypertension 1
• Non-dihydropyridine calcium channel blockers (e.g., diltiazem, verapamil) - particularly effective for vasospastic angina, may require high doses (up to 400-960 mg/day of diltiazem) 1

Lipid-Lowering Medications

• Statins - first-line therapy for reducing cardiovascular risk; reduce LDL cholesterol and improve endothelial function 1
• Fibrates - consider when triglycerides are elevated (200-499 mg/dL) after LDL-lowering therapy 1
• Niacin - option for patients with low HDL or high triglycerides after LDL-lowering therapy 1
• Omega-3 fatty acids - adjunctive therapy for hypertriglyceridemia 1

Antiplatelet Medications

• Aspirin (75-325 mg daily) - recommended for secondary prevention in patients with established vascular disease 1, 3
• Clopidogrel (75 mg daily) - alternative for patients who cannot take aspirin 1, 3
• Dual antiplatelet therapy - for specific indications such as recent acute coronary syndrome or stent placement 1

Medications for Specific Vascular Conditions

Microvascular Angina

• Beta-blockers (first-line) - particularly carvedilol, starting at 6.25 mg twice daily and titrating up 1
• ACE inhibitors - especially beneficial for patients with endothelial dysfunction 1
• Ranolazine, trimetazidine, or ivabradine - additional options for symptom control 1

Vasospastic Angina

• Calcium channel blockers (first-line) - both dihydropyridine and non-dihydropyridine types 1, 2
• Long-acting nitrates - second-line therapy 1
• Nicorandil - third-line option (not available in the US) 1

Peripheral Arterial Disease

• Antiplatelet therapy (aspirin or clopidogrel) - reduces risk of major cardiovascular events 3, 4
• Statins - improve claudication symptoms and reduce cardiovascular risk 3, 4
• Cilostazol - improves walking distance in patients with intermittent claudication 3, 4, 5
• ACE inhibitors - improve walking distance and reduce cardiovascular events 3, 4

Medication Selection Algorithm

1. Assess vascular condition and comorbidities:

   • Hypertension: Start with ACE inhibitor/ARB + calcium channel blocker or thiazide-like diuretic 1
   • Coronary artery disease: Prioritize ACE inhibitor/ARB + beta-blocker 1
   • Peripheral arterial disease: Antiplatelet + statin + ACE inhibitor 3, 4
   • Microvascular disease: Beta-blocker (first-line) + ACE inhibitor 1
   • Vasospastic angina: Calcium channel blocker (first-line) 1, 2

2. Consider fixed-dose combinations to improve adherence, particularly for hypertension management 1

3. Avoid contraindicated combinations:

   • Do not combine ACE inhibitors with ARBs 1
   • Avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors in pregnancy or in women of childbearing potential not using reliable contraception 1

Important Considerations and Pitfalls

• Monitoring requirements: Check serum creatinine, estimated glomerular filtration rate, and potassium levels 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1

• Medication timing: Administer medications at the most convenient time for the patient to improve adherence 1

• Lifestyle modifications: Always combine pharmacotherapy with lifestyle interventions (smoking cessation, regular physical activity, weight management, healthy diet, sodium restriction) for optimal vascular health 1, 6, 7

• Undertreatment: Vascular medications are frequently underutilized, especially in peripheral arterial disease patients without comorbid coronary artery disease 5

• Special populations: Adjust approach for elderly patients (≥85 years), those with orthostatic hypotension, or moderate-to-severe frailty 1