Diabetic Angiopathy - generalized vascular lesion, spreading to small vessels (the so-called "microangiopathy"), as well as to medium and large vessels (ie, macroangiopathy). If changes in small vessels (capillaries, arterioles and venules) are specific for diabetes, then damage to large vessels is equivalent to early and widespread atherosclerosis.
A characteristic feature of lesions of small vessels during is proliferation of the endothelium, thickening of the basement membrane of small capillaries, deposition of glycoprotein RA5-positive substances in the vessel wall. The term "diabetic microangiopathy" has been proposed to refer to a generalized process in small vessels.
Despite the widespread nature of microangiopathies, the vessels of the kidneys, fundus, lower extremities with typical manifestations in the form of nephropathy, retinopathy, and peripheral microangiopathy are much more affected.
The term “diabetic microangiopathy” is the most successful of all proposed, as it reflects the two most characteristic features - the relationship with the underlying disease and the localization of the process in small vessels. Other names, such as "universal capillaryopathy", "disseminated vascular disease", "peripheral angiopathy" have not been grafted into history.
When developing the nomenclature, one should proceed from the established fact about the double vascular damage characteristic of diabetes - atherosclerosis of medium and large vessels, which in diabetes develops earlier and is more common, and about specific diabetic microangiopathy. In addition, another third form of lesion is distinguished - arteriolosclerosis, which is clinically diagnosed only with renal localization of the process.
As for thromboangiitis obliterans (endarteritis), this form of pathogenetic connection with diabetes does not have, and it will be erroneous to classify it as a vascular complication of diabetes. Thromboangiitis is not more common in diabetes than in people without diabetes. A mixture of the concepts of “obliterating atherosclerosis” and “obliterating thromboangiitis” occurred because the last term often refers to early and favorably developing forms of obliterating atherosclerosis. At the same time, thromboangiitis itself is an allergic collagen disease with a clear clinical picture.
Thromboangiitis obliterans can only be discussed with a combination of ischemic syndrome and other symptoms of collagenosis: fever, progressive course, allergic manifestations, inflammatory blood reaction, arthritis, damage to the skin and mucous membranes, systemic involvement of blood vessels. True, at the stage of far-reaching obliteration with the appearance of trophic changes, the leading one may be ischemic syndrome, and signs of allergic inflammation recede into the background. However, their history is mandatory. The above consideration of the staged course of thromboangiitis is illustrated by a classification distinguishing three stages:
stage of trophoparalytic disorders.
There are 3 forms of damage to the vessels of the lower extremities in diabetes mellitus, which are pathogenetically associated with the underlying disease:
- diabetic microangiopathy ,
- atherosclerosis obliterans,
- a combination of atherosclerosis with damage to the vessels of the lower extremities.
Obliterating endarteritis can also occur in patients with diabetes. However, as already indicated, this form does not have a pathogenetic relationship with diabetes, and is not more common than in individuals without diabetes.
When developing the classification of diabetic angiopathies, in addition to the division into two main forms (macro- and microangiopathies), it is advisable to clarify the location of the vascular lesion, since differentiated therapy, in particular local treatment, depends on it. This applies not only to specific microangiopathies (retino-, nephropathy, etc.), but also to the preferential localization of atherosclerosis of medium and large vessels (cerebral, coronary, etc.).
Another principle for classifying diabetic angiopathies must be considered. We are talking about the stage of development of vascular lesions. This question was not raised as long as the prevailing notion of angiopathy was the “late diabetic syndrome” that culminates in long-term diabetes. Indeed, with a long course of the disease, vascular disorders are more often diagnosed, and usually in a far advanced organic stage. As research methods improved, vascular changes began to be detected from the first years of the disease, and even during latent diabetes and prediabetes. Especially often, functional changes in the vessels in the form of changes in diameter, permeability, venous stasis were found from the conjunctiva, glomeruli of the kidneys, lower extremities.
Improving the quality of diagnostic tests has allowed vascular changes to be recognized before complaints and clinical symptoms appear. Due to the functional (reversible) nature of the initial changes in the vessels, the treatment approach will be different compared to the treatment of far-reaching organic vascular lesions.
These considerations served as the basis for the allocation of three stages of diabetic angiopathy:
I - preclinical (metabolic),
II - functional,
III - organic.
Patients with I (preclinical) stage of diabetic angiopathy have practically no complaints. A clinical examination revealed no pathological changes. However, compared with uncomplicated diabetes, at this stage, according to biochemical studies, a more pronounced increase in the level of ester-linked cholesterol (3-lipoproteins, total lipids, agglucoproteins, mucoproteins) is found. Changes in the capillaroscopic picture of the nail bed of the toes of the feet are reduced to an increase in the number of capillaries, a narrowing of the arterial branches, and the appearance of granular blood flow. An increase in vascular tone by tachoscillography and sphygmography is expressed in an increase in average pressure, an increase in the pulse wave propagation velocity (SRWP) to 10.5 m / s and in specific peripheral resistance.
At the II (functional) stage of diabetic angiopathy, there are minor and transient clinical manifestations in the form of pain in the legs during long walks, paresthesias, seizures, a decrease in skin temperature of 2-3 ° C, a decrease in the oscillatory index, and clearer shifts from the capillaries in the form of deformation branch, turbidity, intermittent blood flow. In all patients (mainly up to 40 years), an increase in the tone of arterioles and precapillaries is determined by the above indicators, including an increase in all types of pressure, elastic modulus, PWV up to 11.5 m / s. The same applies to biochemical shifts.
Stage III is characterized by clinically pronounced lesions of the vessels of the legs in the form of intermittent claudication, pain in the feet, trophic disorders of the skin and nails, a sharp decrease or absence of pulse on the dorsal artery of the foot, a drop in the oscillatory index up to the absence of oscillations. In addition to the deformation of capillaries, their obliteration occurs with the appearance of “bald patches”. According to mechanocardiography, patency of the precapillary bed is significantly reduced. The propagation velocity of the pulse wave increases above 11.5 m / s. The main distinguishing feature of patients in stage III of diabetic angiopathy compared with I and II is the irreversible nature of vascular changes, the lack of response to functional tests and low dynamics under the influence of treatment. Most patients of this stage are older than 40 years.
Further progression of the vascular process leads to deeper trophic disorders, non-healing trophic ulcers with a transition to gangrene.
The initial stages of vascular changes (stage I and II of diabetic angiopathy) are characterized by reversible shifts that can appear not only from the first years of diabetes, but even during latent diabetes and prediabetes. It should also be noted that the thickening of the basement membrane of capillaries in connection with a violation of the metabolism of the vascular wall at first is reversible and may appear in the initial stages of vascular changes.
Identification of vascular lesions from the first years of diabetes and even in people with prediabetes gives the right to consider angiopathy not as the end of the disease, but as an integral part of the pathological process, apparently due to a violation of the hormonal regulation of vascular tone and deep metabolic changes.
With all that said, it is most figurative to accept the following clinical classification of diabetic angiopathies.
Clinical classification of diabetic angiopathies.
According to the localization of vascular lesions:
c) generalized microangiopathy, including microangiopathy of internal organs, muscles and skin,
c) microangiopathy of the lower extremities.
Diabetic Angiopathy refers to complications of diabetes and is manifested by malnutrition of limb tissues, which leads to their necrosis. In diabetic angiopathy, vessels of various calibers are affected, but mostly the smallest and medium. Not only the limbs are affected, but also the internal organs.
Damage to small vessels in diabetic angiopathy
When small vessels are affected, changes occur in their wall, blood coagulation is disrupted, and blood flow slows down. All this creates the conditions for the formation of blood clots. The small vessels of the kidneys, retina, heart muscles, and skin are mainly affected. The earliest manifestation of diabetic angiopathy is damage to the lower extremities.
The processes occurring in the vessels are of two types: thickening of the wall of arterioles and veins or thickening of capillaries. Initially, under the influence of toxic products that are formed during the incomplete utilization of glucose, the inner layer of blood vessels swells, after which they narrow.
The first manifestations of diabetic angiopathy are minor hemorrhages under the nail plate of the big toe. The patient feels pain in the limbs, notices that the skin becomes pale, spots appear on it, the nails become brittle, the muscles of the legs “dry out”. The pulse on the main arteries of the lower extremities does not change, but on the foot it can be weak.
Changes in the retinal arteries can be detected and protein in the urine may appear. A specific painless bladder filled with a bloody fluid appears on the skin of the feet. It heals on its own, while a scar does not form, however, microorganisms can enter the tissue and cause inflammation.
To diagnose diabetic angiopathy, the following research methods are used:
- infrared thermography
- the introduction of radioactive isotopes,
- laser fluometry
- polarography or oxyhemography.
Damage to large vessels in diabetic angiopathy
With diabetic angiopathy, medium and large vessels can be affected. In them, the inner shell thickens, calcium salts are deposited and atherosclerotic plaques are formed.
The manifestation of the disease in this case is similar to those that occur with lesions of small arteries. The pain in the feet is disturbing, they become cold and pale, the nutrition of tissues that die off over time is disturbed. Gangrene of the fingers develops, and then the feet.
Diabetic angiopathy of internal organs
In diabetes mellitus, the vessels of the retina and internal organs are most often affected by the pathological process. This is due to the formation of toxic products with incomplete "burning" of glucose. Nearly all patients with high blood glucose have a retinal disease called retinopathy. With this disease, visual acuity first decreases, and then blood is poured into the retina, and it exfoliates. This leads to complete loss of vision.
The second target organ, the vessels of which are affected by diabetes, are the kidneys - nephropathy develops. In the initial stages, the disease does not manifest itself, changes can be detected only during the examination of the patient. Five years later, kidney function is impaired and protein appears in the urine. If changes are identified at this stage, then they can still be reversible. But in the case when treatment is not carried out, the pathological process in the vessels of the kidneys progresses, and after ten years visible signs of the disease appear. First of all, a large amount of protein begins to be excreted in the urine. It becomes less in the blood, and this leads to the accumulation of fluid in the tissues and swelling. Initially, edema is visible under the eyes and on the lower extremities, and then the fluid accumulates in the chest and abdominal cavities of the body.
The body begins to use its own protein substances for life, and patients lose weight very quickly. They have weakness, headache. Also at this time, blood pressure rises, which stubbornly keeps at high numbers and does not decrease under the influence of medications.
The end result of diabetic renal angiopathy is the final stage of renal failure. The kidneys almost completely fail, they do not fulfill their function, and urine is not excreted. Poisoning of the body by protein metabolism occurs.
Diabetic angiopathy Treatment at different stages of the disease
Successful treatment of diabetic angiopathy is possible only when it is possible to normalize blood glucose levels. This is what endocrinologists do.
In order to prevent irreversible processes in tissues and organs, it is necessary:
- control blood sugar and urine
- make sure that blood pressure does not exceed 135/85 mm. Hg. Art. in patients without protein in the urine, and 120/75 mm. Hg. Art. in patients whose protein is determined,
- control the processes of fat metabolism.
In order to maintain blood pressure at the right level, patients with diabetes need to change their lifestyle, limit their intake of sodium chloride, increase physical activity, maintain normal body weight, limit their intake of carbohydrates and fats, and avoid stress.
When choosing drugs that lower blood pressure, you need to pay attention to whether they affect the metabolism of fats and carbohydrates, and whether they have a protective effect on the kidneys and liver. The best remedies for these patients are captopril, verapamil, valsartan. Beta-blockers should not be taken, as they can contribute to the progression of diabetes.
Patients with diabetic angiopathy are shown taking statins, fibrates, as well as medications that improve fat metabolism. In order to maintain a normal level of glucose in the blood, it is necessary to take glycidone, repaglimid. If diabetes progresses, patients should be switched to insulin.
Diabetic angiopathy requires constant monitoring of glucose levels, fat metabolism and vascular status. When necrosis of limb tissues is performed, operations to remove them are performed.In the case of chronic renal failure, the only way to prolong the patient’s life is an “artificial” kidney. With retinal detachment as a result of diabetic angiopathy, surgery may be necessary.
In patients with diabetes, signs of diabetic angiopathy are often manifested when small vessels are affected. Diabetic angiopathy of the lower extremities is most often diagnosed, while a complication of this kind occurs in diabetics with type 1 or type 2 pathology. If surgical or conservative treatment for diabetic angiopathy is not performed on time, serious complications with damage to many organs are possible.
What kind of disease?
Diabetic angiopathy is characterized by damage to small and large vessels and arteries. The disease code for MBK 10 is E10.5 and E11.5. As a rule, diabetic foot disease is noted, but damage to the vessels of other parts of the body and internal organs is also possible. It is customary to subdivide angiopathy in diabetes into 2 types:
- Microangiopathy. It is characterized by the defeat of capillaries.
- Macroangiopathy Arterial and venous lesions are noted. This form is less common, and affects diabetics who have been sick for 10 years or longer.
Often, due to the development of diabetic angiopathy, the patient's general well-being worsens and life expectancy is reduced.
The main causes of diabetic angiopathy
The main reason for the development of diabetic angiopathy is regularly elevated blood sugar levels. The following causes are identified leading to the development of diabetic angiopathy:
- prolonged hyperglycemia,
- increased concentration of insulin in the blood fluid,
- the presence of insulin resistance,
- diabetic nephropathy, in which renal dysfunction occurs.
Not all diabetics have such a complication, there are risk factors when the likelihood of vascular damage increases:
- prolonged course of diabetes,
- age category over 50 years old,
- wrong way of life
- malnutrition, with a predominance of fatty and fried,
- slowing down metabolic processes,
- excess weight
- excessive consumption of alcohol and cigarettes,
- arterial hypertension,
- Heart arythmy,
- genetic predisposition.
It is difficult to predict the occurrence of diabetic angiopathy. More often angiopathy of the lower extremities is noted, since they are heavily loaded with diabetes. But vascular, arterial, capillary damage to other parts of the body is possible. Target organs are distinguished, which more often than others suffer from angiopathy:
Symptoms of pathology
Early diabetic angiopathy may not show any special signs, and a person may not be aware of the disease. As progression manifests itself, various pathological symptoms that are difficult not to notice. Symptomatic manifestations depend on the type and stage of the vascular lesion. The table shows the main stages of the disease and characteristic manifestations.
Diabetic angiopathy of the vessels of the lower extremities is detected through laboratory and instrumental studies.
It is recommended that you also consult an endocrinologist, nephrologist, neurologist, optometrist, cardiologist, gynecologist, angiologist surgeon, podiatrist or other specialists. The following studies are prescribed for diabetes:
- general analysis of urine and blood,
- blood biochemistry for sugar, cholesterol and other lipids,
- Ultrasound of the vessels of the brain and neck, legs, heart and other target organs,
- blood pressure measurement
- glycated hemoglobin analysis,
- glucose tolerance test.
In diabetic angiopathy, complex treatment is required, which involves taking drugs of different groups and observing a strict diet and regimen. Before treating the pathology, you should abandon the consumption of alcohol and drugs, which negatively affect the vessels. The pharmacotherapy of diabetic angiopathy is to take the following drugs:
- Cholesterol-lowering drugs:
- Blood thinners:
- Means that improve blood circulation and microcirculation:
Ibuprofen is prescribed for pain that bothers the patient.
In addition, the doctor will recommend treatment with vitamin E or nicotinic acid. If the patient is worried about severe pain in diabetic angiopathy, then painkillers are indicated: Ibuprofen, Ketorolac. If a secondary infectious lesion has joined, then antibacterial medicines are indicated: Ciprinol, Ceftriaxone.
Many patients with diabetes suffer from many concomitant diseases that worsen their condition, affecting all organs and blood vessels. One of these diseases is attributed. Its essence lies in the fact that all blood vessels are damaged. If only small vessels are damaged, then this is diabetic microangiopathy. In the event that only large vessels were affected during the disruption of blood vessels, this is a diabetic macroangiopathy. Such damage is not the only problem of the patient. In addition, with angiopathy, homeostasis is impaired.
Features of diabetic microangiopathy
If we consider the main features of microangiopathy, then there are three factors that are called the Virchow-Sinako triad.
These signs are as follows:
- The process by which the walls of blood vessels change.
- The process in which blood coagulation is impaired.
- Decreased blood speed. Due to increased platelet activity and increased density, the blood becomes more viscous. Moreover, with proper blood flow and vascular function, the walls of the vessels have a special lubricant that does not allow blood to stick to them. Violation of the structure of the walls of blood vessels can cause problems with the production of this lubricant.
All the factors presented lead to the fact that not only the vessels are destroyed, but also microtrombi appear.
Such transformations in the process of the development of the disease begin to affect an increasing number of vessels. Most often, the main lesion area is the eyes, kidneys, myocardium, skin, peripheral nervous system. These processes lead to the development of cardiopathy, nephropathy, neuropathy, dermatopathy and other disorders. The first symptoms are disorders in the blood vessels of the lower extremities. This occurs in approximately 65% of cases.
Some medical scientists are inclined to think that microangiopathy should not be distinguished as a separate disease and it is a symptom of diabetes. Moreover, they believe that before this syndrome occurs, neuropathy first appears, which leads to microangiopathy. Other scientists believe that it is nerve ischemia that causes neuropathy and this is not associated with damage to blood vessels. In this theory, neuropathy is a consequence of diabetes mellitus, which is not related to the processes caused by microangiopathy. The third group of scientists hypothesizes that if the work of nerves is disrupted, then the blood vessels begin to malfunction.
The following types of diabetic microangiopathy are distinguished according to the level of damage to the lower extremities:
- Zero level at which there is no damage to the skin of a person.
- The first level, when there are some flaws on the skin, but they are narrowly localized and do not have any inflammatory processes.
- The second level, at which deeper skin lesions form. They, in turn, can deepen to such an extent that they damage bones and tendons.
- The third level, at which there are ulcers on the skin and the beginning of the death of tissues on the lower extremities. Such complications can occur along with infections, inflammatory processes, edema, abscesses, hyperemia and osteomyelitis.
- The fourth level of the disease is when gangrene of one and several fingers develops. This process can begin not from the fingers, but from the side of the foot.
- The fifth level of the disease, when the gangrene affects most of the foot or the entire foot completely.
Features of the development of diabetic macroangiopathy
Diabetic macroangiopathy is the main factor in mortality of patients with diabetes mellitus. Most often, such a complication as macroangiopathy occurs in patients. First, large blood vessels of the lower extremities are affected. First of all, cerebral and coronary arteries are affected. Such a disease can develop when the process of increasing the rate of development of atherosclerosis begins.
Several stages of the development of macroangiopathy can be distinguished. At first, limited movements in the morning, increased fatigue, drowsiness and weakness, a feeling of coldness in the extremities, increased sweating and some numbness of the extremities appear. These are symptoms of compensation in the peripheral circulation. Then comes the second stage, when a person can freeze very much, his legs are numb, the surface of the nails is broken. Lameness may appear at this stage. Then pain can occur both when moving and in a calm state. Convulsions appear, the skin turns pale and thinner. Joints are disturbed. At the last stage, gangrene develops on the foot, fingers and lower leg.
Treatment of angiopathy in diabetes
With diabetic micro- and macroangiopathy, the principles of treatment are approximately similar. First of all, it is necessary to bring metabolic processes to a normal healthy state. It is very important to restore carbohydrate metabolism, because it is hyperglycemia that can affect the development of atherosclerosis.
The second principle in the treatment of these diseases is the control of all data on lipid metabolism. If the level of lipoproteins has increased, which have low density indicators, and the level of triglycerides decreases, then drugs with hypolipidemic prescription should be used in treatment. These include antioxidants, fibrates, and statins.
During the treatment of macro- and microangiopathy in diabetes mellitus, drugs that have a metabolic effect are necessarily used. These drugs include trimetazidine. Drugs of this kind can contribute to the process of glucose oxidation in the myocardium. This is due to the oxidation of fatty acids.
During the treatment of micro- and macroangiopathy in diabetes mellitus, such drugs are prescribed that promote the resorption of blood clots in the blood and weaken the function of platelets. This is necessary so that the blood is not too thick in its consistency and does not create clogging of blood vessels. These drugs include ticlide, acetylsalicylic acid, heparin, dipyridamole, vazaprostan and some others.
It is also necessary to use drugs that can normalize blood pressure. If it is normal, then control and monitoring of this indicator is necessary. The optimal level in these conditions will be considered 130 to 85 mm RT. Art. Such precautions help prevent the development of retinopathy and nephropathy. Moreover, this will help not to be at risk of a heart attack or stroke. Among the drugs that contribute to the normalization of pressure, inhibitors, calcium channel antagonists and other drugs are distinguished.
»» No. 9-10 "99" »New Medical Encyclopedia
- It has been established that the pathogenesis of abdominal (android) type of obesity, combined with hyperglycemia, insulin resistance (IR) and hyperinsulinemia (GI), is due to a decrease in sex steroid-binding globulin, an increase in the activity of androgens, which leads to an increase in the size of adipocytes and their insulin resistance.
- Arterial hypertension (observed in 40-60% of patients with diabetes) is a leading factor in the development of diabetic nephropathy, which leads to impaired elimination of atherogenic fractions of lipoproteins and accelerates atherosclerosis.
- Prolonged use of certain antihypertensive drugs may have a negative effect on lipid and carbohydrate metabolism.
- In patients with diabetes, hypertriglyceridemia and a decrease in high density lipoproteins (HDL) are observed, which is the most powerful and independent factor in cardiovascular pathology.
- Diabetic macroangiopathies (MA) in accordance with localization and clinical manifestations are divided into the following groups:
- vascular lesions of the heart (coronary heart disease, myocardial infarction),
- cerebrovascular disease (acute and chronic cerebrovascular accident)
- lesions of peripheral arteries, including the lower extremities (gangrene).
- The frequency of development of MA in patients with diabetes is 2-3 times higher than in individuals without impaired carbohydrate metabolism.
- Raven (Reaven) for the first time noted the frequent combination of hyperinsulinemia, android obesity, arterial hypertension, hypertriglyceridemia in patients with impaired carbohydrate tolerance. The combination of these disorders is called metabolic syndrome "X".
- The frequency of development of coronary heart disease in men with diabetes is 2 times, and in women - 3 times higher than the frequency of coronary heart disease in individuals without impaired carbohydrate metabolism.
- The mortality rate of patients with diabetes from coronary heart disease under the age of 55 years is 35%.
- About half of all non-traumatic lower limb amputations are performed in patients with diabetes.
Diabetic macroangiopathies (MA) are a fairly common pathology in patients with diabetes mellitus (DM), the main reason for their mortality and disability. Currently, this group of complications is commonly called "diabetic macrovascular disease."
Etiology and pathogenesis
An increased risk of developing cardiovascular disease in patients with diabetes is due to a number of reasons. They are usually divided into non-specific ones - arterial hypertension (AH), obesity, smoking, physical inactivity, hyperlipidemia and heredity - and specific ones - chronic hyperglycemia, hyperinsulinemia, changes in the rheological properties of blood and vascular architectonics, microalbuminuria and a violation of the adaptive response of cells in conditions of ischemia. Obviously, the interaction of factors of both groups significantly accelerates the development of atherosclerosis, which is a morphological substrate of MA.
The pathogenetic mechanisms underlying the development of MA are not fully understood.
Chronic hyperglycemia (see chart) appears to be an important component for the formation of angiopathies. Hyperglycemia is known to cause non-enzymatic glycosylation of proteins to form an intermediate called the Amadori product. Subsequently, Amadori's product undergoes a slow and irreversible transformation into complex compounds, which are found in the connective tissue of blood vessels, the phospholipid component of LDL and as part of thickened basement membranes. In this case, free radicals are formed that have powerful oxidative activity. All this leads to an increase in permeability and a decrease in vascular elasticity, a change in the function of enzymes and lipoprotein metabolism. Glycosylated LDL is easily oxidized and has a large affinity for macrophages, which leads to the formation of "foamy cells", which are the main element of atherogenesis.
The blood coagulation system is also disturbed, which manifests itself in an increase in platelet activity, hyperfibrinemia and an increase in factors V, VII, VIII, and blood fibrinolytic activity decreases. The balance between the ratio of vasodilators (NO, PG12) and vasoconstrictors (TxA2) is significantly upset. The listed mechanisms lead to the formation of microthrombi, causing disturbances in microcirculation and arterial occlusion.
Features of the clinical picture
Damage to coronary, cerebral and peripheral vessels in patients with diabetes leads to pathology of the corresponding localization.
Coronary heart disease (CHD) is a leading cause of death in diabetes patients. The clinical manifestations of coronary heart disease in diabetes have their own characteristics:
- the same incidence of coronary heart disease in men and women,
- a high incidence of “atypical” forms of IHD (painless, arrhythmic and other variants) and myocardial infarction, and as a result, a high risk of “sudden coronary death”,
- high frequency of post-infarction complications: cardiogenic shock, thromboembolic complications, the formation of acute and chronic aneurysms, rhythm and conduction disturbances, congestive heart failure,
- high risk of recurring myocardial infarction,
- a 2-fold increase in mortality from myocardial infarction compared with patients not suffering from diabetes.
The defeat of the peripheral vessels of the lower extremities is a frequent and pronounced manifestation of diabetes, clinically manifested by alternating claudication and ischemic foot. The frequency of intermittent claudication in men with diabetes is 4 times higher, and that of women is 6 times higher than that in the general population. Obstruction of the arteries of the lower extremities causes severe pain in the calves, hips, and sometimes in the buttocks, provoked by physical exertion. With a sharp violation of the blood flow, necrosis of the tissues of the feet and legs can occur, which leads to the development of gangrene. Less pronounced blood flow disorders are combined with diabetic neuropathy and infection, which leads to chronic ulceration, leading to destruction of bones and soft tissues.
Table 3. The choice of drugs for the correction of dyslipidemia in patients with diabetes mellitus
Essential measures for the prevention of MA:
Reduced alcohol consumption,
Weight loss in obese people,
Regular dosed physical activity,
Drug treatment methods should be aimed at ensuring optimal glycemic control, correction of arterial hypertension, and treatment of dyslipidemia (Table 1). Undoubtedly an important point is the correction of hyperglycemia. There is evidence of a positive effect of sulfonylurea preparations on lipid metabolism and rheological properties of blood. Biguanides are the drugs of choice for obese patients with NIDDM. The intake of these drugs is accompanied by weight loss, a decrease in insulin resistance and an increase in the fibrolytic activity of the blood. Acarbose preparations are widely used to correct postprandial hyperglycemia, and also reduce triglycerides. Combination therapy with sulfanylurea and insulin preparations can also have a positive metabolic effect, improve the lipid profile. However, it is not recommended to use high doses of insulin in patients with NIDDM, as this can cause chronic hyperinsulinemia and increase blood atherogenicity. Treatment of hypertension is an important part in the prevention of MA. Correction of hypertension should begin with an increase in blood pressure above 140/90 mm RT. Art. Metabolically neutral drugs are preferred - ACE inhibitors, calcium channel blockers, selective beta blockers. The use of thiazide diuretics and non-selective beta-blockers should be limited due to their effect on glucose and lipid metabolism. Patients with peripheral vascular disease are not recommended to prescribe selective beta-blockers.
If the correction of dyslipidemia is not achieved by observing a healthy lifestyle, diet (Table 2), glycemic control and blood pressure, then drug therapy is necessary.
The purpose of lipid-lowering therapy depends on the type of dyslipidemia (Table 3). With an increase in total cholesterol and VLDL cholesterol, HMG-CoA reductase inhibitors (statins) or resins are prescribed. Sequestrants of bile acids are used less often, as they can cause an increase in triglycerides. In isolated hypertriglyceridemia, fibrates and nicotinic acid analogues are prescribed. The latter can increase the level of glycemia, which requires careful monitoring of blood glucose in the first months of treatment. Great expectations in the treatment of dyslipidemia are associated with a new drug from the group of fibrates - gemfibrozil. In addition to the lipid-lowering effect, the drug also reduces insulin resistance, which is important for patients with NIDDM.
Undoubtedly, drugs that improve cerebral blood flow, such as instenon, vinpocetine, and others, are often useful for the prevention and treatment of coronary artery disease, which is often observed in patients with diabetic macroangiopathies. Especially promising is the use of instenon. The drug is interesting in a successful combination of vasoactive and neurotrophic agents that can affect various pathogenesis links of hypoxic and ischemic brain damage, accelerating metabolic processes in the nervous tissue and, indirectly, through other systems and organs (lungs, heart, kidneys, etc.), positively influencing on the functional state of the nervous system. Instenon components have a stimulating effect on the neurons of certain structures and systems of the brain, improve microcirculation in ischemic zones, blocking the vasoconstriction of intracranial arterioles and capillaries, significantly activate the body's antiperoxidant system, which leads to a decrease in the concentration of lipid peroxidation products, increase anaerobic glycolysis and increase and oxygen to neurons. In conclusion, it should be noted that preventive measures aimed at reducing the risk factors of macroangiopathies play an important role in preventing the development of acute vascular disorders.
Boris Vladimirovich Romashevsky - Department of Therapy for Advanced Medical Studies, Russian Medical Academy, St. Petersburg
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The inner wall of the vessels is in direct contact with the blood. It represents endothelial cells that cover the entire surface in one layer. The endothelium contains inflammatory mediators and proteins that promote or inhibit blood coagulation. It also works as a barrier - it passes water, molecules less than 3 nm, selectively other substances. This process provides the flow of water and nutrition into the tissues, cleansing them of metabolic products.
With angiopathy, it is the endothelium that suffers the most, its functions are impaired. If diabetes is not kept under control, elevated glucose levels begin to destroy vascular cells. Special chemical reactions occur between endothelial proteins and blood sugars - glycation. The products of glucose metabolism gradually accumulate in the walls of blood vessels, they thicken, swell, stop working as a barrier. Due to the violation of the coagulation processes, blood clots begin to form, as a result - the diameter of the vessels decreases and the movement of blood slows down in them, the heart has to work with an increased load, blood pressure rises.
The smallest vessels are most damaged, the circulatory disturbance in them leads to the cessation of oxygen and nutrition in the body tissue. If in areas with severe angiopathy in time there is no replacement of the destroyed capillaries with new ones, these tissues atrophy. A lack of oxygen prevents the growth of new blood vessels and accelerates the overgrowth of damaged connective tissue.
These processes are especially dangerous in the kidneys and eyes, their performance is impaired until the complete loss of their functions.
Diabetic angiopathy of large vessels is often accompanied by atherosclerotic processes. Due to impaired fat metabolism, cholesterol plaques are deposited on the walls, the lumen of the vessels narrows.
Disease development factors
Angiopathy develops in patients with type 1 and type 2 diabetes only if blood sugar is elevated for a long time. The longer the glycemia and the higher the sugar level, the faster the changes in the vessels begin. Other factors can only aggravate the course of the disease, but not cause it.
|Angiopathy Development Factors||The mechanism of influence on the disease|
|Diabetes duration||The likelihood of angiopathy increases with the experience of diabetes, as changes in the vessels accumulate over time.|
|Age||The older the patient, the higher the risk of developing diseases of large vessels. Young diabetics are more likely to suffer from impaired microcirculation in organs.|
|Vascular pathology||Concomitant vascular diseases increase the severity of angiopathy and contribute to its rapid development.|
|Availability||Elevated levels of insulin in the blood accelerates the formation of plaques on the walls of blood vessels.|
|Short coagulation time||Increases the likelihood of blood clots and capillary mesh dying.|
|Excess weight||The heart wears out, the level of cholesterol and triglycerides in the blood rises, the vessels narrow faster, the capillaries located far from the heart are worse supplied with blood.|
|High blood pressure||Enhances the destruction of the walls of blood vessels.|
|Smoking||It interferes with the work of antioxidants, reduces the level of oxygen in the blood, increases the risk of atherosclerosis.|
|Stand-up work, bed rest.||Both lack of exercise and excessive leg fatigue accelerate the development of angiopathy in the lower extremities.|
What organs are affected by diabetes
Depending on which vessels suffer the most from the influence of sugars in uncompensated diabetes, angiopathy is divided into types:
- - represents a defeat of the capillaries in the glomeruli of the kidneys. These vessels are among the first to suffer, as they work under constant load and pass a huge amount of blood through themselves. As a result of the development of angiopathy, renal failure occurs: blood filtration from metabolic products deteriorates, the body does not completely get rid of toxins, urine is excreted in a small volume, edema, constricting organs form throughout the body. The danger of the disease lies in the absence of symptoms in the initial stages and a complete loss of kidney function in the final. The disease code according to the classification of ICD-10 is 3.
- Diabetic angiopathy of the lower extremities - most often develops as a result of the influence of diabetes on small vessels. Circulatory disorders leading to trophic ulcers and gangrene can develop even with minor disorders in the main arteries. It turns out a paradoxical situation: there is blood in the legs, and the tissues are starving, since the capillary network is destroyed and does not have time to recover due to the constantly high blood sugar. Angiopathy of the upper extremities is diagnosed in isolated cases, since a person’s hands work with less load and are located closer to the heart, therefore, the vessels in them are less damaged and recover faster. The code for ICD-10 is 10.5, 11.5.
- - leads to damage to the vessels of the retina. Like nephropathy, it does not have symptoms until the serious stages of the disease, which require treatment with expensive drugs and laser surgery on the retina. The result of vascular destruction in the retina is blurred vision due to edema, gray spots in front of the eyes due to hemorrhages, detachment of the retina followed by blindness due to scarring at the site of damage. Initial angiopathy, which can only be detected in the ophthalmologist’s office, is cured on its own with long-term diabetes compensation. Code H0.
- Diabetic angiopathy of the heart vessels - leads to angina pectoris (code I20) and is the main cause of death from complications of diabetes. Atherosclerosis of the coronary arteries causes oxygen starvation of the heart tissue, to which it responds with pressing, compressive pain. The destruction of the capillaries and their subsequent overgrowing with connective tissue impairs the function of the heart muscle, rhythm disturbances occur.
- - violation of the blood supply to the brain, in the beginning manifested by headaches and weakness. The longer hyperglycemia, the greater the oxygen deficiency of the brain, and the more it is affected by free radicals.
Symptoms and signs of angiopathy
At first, angiopathy is asymptomatic. While the destruction is uncritical, the body manages to grow new vessels to replace the damaged one. At the first, preclinical stage, metabolic disorders can be determined only by increasing cholesterol in the blood and increasing vascular tone.
The first symptoms of diabetic angiopathy occur at the functional stage, when the lesions become extensive and do not have time to recover. The treatment started at this time can reverse the process and completely restore the function of the vascular network.
- leg pain after a long load -,
- numbness and tingling in the limbs,
- cold skin on the feet
- protein in the urine after exercise or stress,
- spots and blurred vision,
- weak headache, not relieved by analgesics.
Well-defined symptoms occur at the last, organic, stage of angiopathy. At this time, changes in the affected organs are already irreversible, and drug treatment can only slow down the development of the disease.
- Constant pain in the legs, lameness, damage to the skin and nails due to lack of nutrition, swelling of the feet and calves, inability to stay in a standing position for a long time with angiopathy of the lower extremities.
- High, not amenable to therapy, blood pressure, swelling on the face and body, around the internal organs, intoxication with nephropathy.
- Severe vision loss with retinopathy, fog before the eyes as a result of edema in diabetic angiopathy of the center of the retina.
- Dizziness and fainting due to arrhythmia, lethargy and shortness of breath due to heart failure, chest pain.
- Insomnia, impaired memory and coordination of movements, a decrease in cognitive abilities in brain angiopathy.
Symptoms of vascular lesions in the limbs
|Pale, cool skin of the feet||Capillary disruption still treatable|
|Leg muscle weakness||Inadequate muscle nutrition, the onset of angiopathy|
|Redness on the feet, warm skin||Inflammation due to joining infection|
|Lack of pulse on the limbs||Significant narrowing of the arteries|
|Prolonged edema||Severe vascular damage|
|Reducing calves or thigh muscles, stopping hair growth on the legs||Prolonged oxygen starvation|
|Non-healing wounds||Multiple capillary damage|
|Black color fingertips||Vascular angiopathy|
|Blue cold skin on the limbs||Severe damage, lack of blood circulation, beginning gangrene.|
Characteristic Signs of Diabetic Microangiopathy
When considering the main signs of microangiopathy, three main factors stand out, called the Virchow-Sinako triad. What are these signs?
- The walls of the vessels undergo changes.
- Blood coagulation is impaired.
- Blood speed decreases.
As a result of increased platelet activity and increased blood density, it becomes more viscous. Healthy vessels have a special lubricant that does not allow blood to adhere to the walls. This ensures proper blood flow.
Disturbed vessels cannot produce this lubricant, and there is a slowdown in blood movement. All these violations lead not only to the destruction of blood vessels, but also to the formation of microtubuses.
In the process of developing diabetes mellitus, this kind of transformation involves an even greater number of vessels. Often the main area of damage is:
- organs of vision
- peripheral nervous system
- skin integument.
The consequence of these violations, as a rule, are:
- diabetic nephropathy,
But the first symptoms appear in the lower extremities, which is caused by a violation of the blood vessels in this area. Registration of such cases is approximately 65%.
Some doctors tend to argue that microangiopathy is not a separate disease, that is, it is a symptom of diabetes. In addition, they believe that microangiopathy is a consequence of neuropathy, which occurs before.
Other scientists claim that nerve ischemia causes neuropathy, and this fact is not associated with vascular damage. According to this theory, diabetes mellitus causes neuropathy, and microangiopathy has nothing to do with it.
But there is also a third theory, the adherents of which argue that a violation of the nervous function will malfunction the blood vessels.
Diabetic microangiopathy is divided into several types, which are caused by the degree of damage to the lower extremities.
- With a zero degree of damage to the skin on the human body are absent.
- The first level - there are small flaws on the skin, but they do not have inflammatory processes and are narrowly localized.
- At the second level, more noticeable skin lesions appear that can deepen so that they damage the tendons and bones.
- The third level is characterized by skin ulcers and the first signs of tissue death on the legs. Such complications can occur in conjunction with inflammatory processes, infections, edema, hyperemia, abscesses and osteomyelitis.
- At the fourth level, the gangrene of one or several fingers begins to develop.
- The fifth level is the entire foot, or most of it is affected by gangrene.
The characteristic features of macroangiopathy
The main factor in the high mortality of patients with diabetes is diabetic macroangiopathy. It is macroangiopathy that most often occurs in diabetic patients.
First of all, large vessels of the lower extremities are affected, as a result of which coronary and cerebral arteries suffer.
Macroangiopathy can develop in the process of increasing the rate of development of atherosclerotic disease. The disease is divided into several stages of development.
- At the first stage, in the morning the patient has increased fatigue, excessive sweating, weakness, drowsiness, a feeling of coldness in the limbs and their slight numbness. This signals compensation in the peripheral circulation.
- In the second stage, a person’s legs begin to go numb, he freezes very much, the surface of the nails begins to break. Sometimes lameness appears at this stage. Then there is pain in the limbs, both when walking and at rest. The skin becomes pale and thin. Disturbances in the joints are observed.
- The last stage is gangrene in diabetes mellitus of the foot, fingers and lower leg.
How to treat angiopathy
Macro and microangiopathy in diabetes is treated approximately the same. The very first thing a patient should do is bring the metabolic processes of the body to a normal state. Carbohydrate metabolism should be restored, because hyperglycemia is the main reason for the development of atherosclerosis of blood vessels.
Equally important in the treatment process is monitoring the state of lipid metabolism. If the level of lipoproteins with low density indicators suddenly increased, and the level of triglycerides, on the contrary, decreased, this suggests that it is time to include hypolipidic drugs in the treatment.
We are talking about statins, fibrates and antioxidants. Macro- and microangiopathy in diabetes mellitus is treated with the obligatory inclusion of therapeutic drugs of metabolic action, for example, trimetazidine.
Such medications contribute to the process of oxidation of glucose in the myocardium, which occurs due to the oxidation of fatty acids. During the treatment of both forms of the disease, patients are prescribed anticoagulants.
These are drugs that help resolve blood clots in the bloodstream and weaken platelet function when diagnosed with macroangiopathy.
Thanks to these substances, the blood does not acquire a thick consistency and the conditions for clogging of blood vessels are not created. Anticoagulants include:
- Acetylsalicylic acid.
Important! Since hypertension is almost always present in diabetes mellitus, it is necessary to prescribe medications that normalize blood pressure. If this indicator is normal, it is still recommended to constantly monitor it.
In diabetes mellitus, the optimal values are 130/85 mm Hg. Such control measures will help to prevent the development of nephropathy and retinopathy in a timely manner, significantly reduce the risk of stroke and heart attack.
Among these drugs, calcium channel antagonists, inhibitors and other drugs are distinguished.
During treatment, it is necessary to normalize the indicators of autonomic homeostasis. For this, doctors prescribe drugs that increase the activity of sorbitol dehydrogenase. It is equally important to carry out activities that promote antioxidant protection.
Of course, it is best to prevent the disease initially. To do this, you need to lead the right lifestyle and constantly monitor your health. But if signs of diabetes nevertheless appeared, you should immediately contact a medical institution.
Modern methods of diabetes treatment and preventive support will help a person avoid such dire consequences as macro- and microangiopathy.