VSD is a disease that develops in the presence of genetic and acquired factors leading to disruption of the neurohumoral and endocrine regulation of the tone of the autonomic nervous system. The clinical picture of vegetative-vascular dystonia is characterized by a variety of symptoms and depends on age, gender and the severity of autonomic dysfunction.
At the Yusupov Hospital, for the treatment of patients suffering from VSD, medications are used that have a pronounced therapeutic effect and do not have significant side effects. Patients respond well to the treatment methods used by neurologists, cardiologists, and rehabilitation specialists.
There is no single drug that can be used to cure vegetative-vascular dystonia. Complex drug therapy for VSD includes etiological, pathogenetic and symptomatic treatment. Nootropic drugs (phenibut, fezam, piracetam) for VSD improve the nutrition of brain cells, regulate the processes of excitation and inhibition of the central nervous system, reduce psychological stress and anxiety levels. Trental for VSD dilates the coronary vessels, reduces pain and discomfort in the heart area. Vitamin-mineral complexes (neuromultivitis) are an integral component of VSD therapy.
Nootropic drugs for the treatment of VSD
The main task of nootropic drugs is to activate the elements through which nerve cells – neurotransmitters – communicate with each other. Nootropic drugs contain substances that activate the process of biosynthesis of ribonucleic acid and protein compounds in the central nervous system. They accelerate energy processes in neurons, help reduce the number of free radicals, as a result of which they neutralize the negative effects of oxidants.
For VSD, piracetam and its derivatives (ethiracetam, isacetam, oxiracetam) have been used for many years. New generation nootropic drugs include:
- fezam;
- noopept;
- mildronate;
- phenotropil;
- noben;
- Ceraxon;
- pantocalcin;
- pantogam;
- cortexin.
The nootropic drug "Phesam" for VSD, due to the combination of cinnarizine and piracetam, the drug has an antihypoxic, vasodilating effect, improves blood circulation in the brain, and the functions of the auditory and visual analyzers. The main component of phenibut is aminophenylbutyric acid. This compound, a derivative of phenylethylamine and gamma-aminobutyric acid (GABA), plays an important role in the activity of brain neurons - it normalizes metabolism in nerve tissues and signal transmission between neurons. Phenibut plays an important role in strengthening cortico-subcortical connections. This increases the efficiency of interaction between different parts of the cerebral cortex, which is impaired in patients suffering from VSD. After taking the drug, memory improves, the speed and volume of memorized information increases, and emotional stability increases. In patients with VSD, under the influence of Phezam, the activity of mental processes is stimulated, depression, emotional excitability and irritability are reduced.
Noopept restores memory and enhances cognitive abilities, normalizes the activity of the autonomic nervous system. The drug improves mood, increases vitality, relieves stress and anxiety.
Mildronate for VSD (reviews about the drug are good) is used in the form of tablets for oral administration and injections. It has the following effect:
- increases performance;
- reduces symptoms of mental and physical stress;
- activates humoral and tissue immunity;
- has a cardioprotective effect.
Phenotropil acts on most neurotransmitter systems of the brain. When VSD has the following effect:
- activates the integrative activity of the brain;
- promotes memory consolidation;
- improves mental activity and concentration;
- facilitates learning processes;
- accelerates the transfer of information between the hemispheres of the brain;
- increases the resistance of brain tissue to toxic effects and hypoxia;
- regulates the processes of activation and inhibition of the central nervous system;
- improves mood;
- has anticonvulsant and anxiolytic activity.
Noben improves metabolic processes in the brain. It has an antioxidant effect, a psychostimulating effect and neuroprotective properties. From the first days of taking the drug Noben for VSD, antiasthenic, psychostimulating and antidepressant effects are manifested.
Due to the presence of the main active ingredient citicoline in the composition of the drug, Ceraxon has many effects:
- promotes restoration of damaged cell membranes;
- inhibits the action of phospholipases, preventing the excessive formation of free radicals;
- prevents the death of brain cells.
Pantocalcin is a nootropic and psychostimulant drug. In VSD, it has neurometabolic, neuroprotective and neurotrophic effects. Improves memory, reduces lack of initiative and difficulties that arise when performing everyday activities.
The effect of pantogam in VSD is associated with the presence of gamma-aminobutyric acid in its structure. The drug has a nootropic and anticonvulsant effect. Has the following effects:
- increases the brain’s resistance to the effects of toxic substances and hypoxia;
- stimulates anabolic processes in neurons;
- reduces motor excitability;
- combines a moderate sedative effect with a mild stimulating effect;
- activates physical and mental performance.
Neurologists prescribe Cortexin to patients for the treatment of vegetative-vascular dystonia. In case of VSD, the drug improves higher brain functions, memory and learning processes, concentration, and resistance to stress. Protects neurons from damage by various endogenous neurotoxic factors, reduces the toxic effects of psychotropic substances. Increases the survival of neurons under conditions of hypoxia and oxidative stress. Activates the metabolism of neurons, helps improve the functions of the cerebral cortex and the tone of the autonomic nervous system
Drugs that improve cerebral circulation in VSD
Doctors at the Yusupov Hospital use drugs that improve cerebral circulation in the complex treatment of VSD. The composition of the drug Vasobral includes alpha-dihydroergocriptine, a dehydrogenated derivative of ergot. This substance blocks α1- and α2-adrenergic receptors of vascular smooth muscle cells. The drug improves cerebral circulation in VSD.
Nicergoline improves metabolic and hemodynamic processes in the brain. The drug reduces platelet aggregation and improves the physicochemical properties of blood. When using the drug, the permeability of the vascular wall decreases, blood circulation and metabolism in the brain improve, and the resistance of brain tissue to hypoxia increases. Caffeine, which is part of the drug, stimulates the central nervous system. In patients suffering from VSD, mental and physical performance increases and the feeling of fatigue decreases.
Vinpocetine for VSD improves cerebral circulation and metabolism in brain neurons. The drug increases the resistance of neurons to hypoxia and helps increase oxygen delivery to red blood cells. Vinpocetine increases cerebral blood flow, reduces cerebral vascular resistance without significantly changing systemic circulatory parameters (blood pressure, minute volume, heart rate).
Picamilon has an effective nootropic effect for VSD. Reviews about the drug are good. In case of VSD, the drug dilates the blood vessels of the brain, has a tranquilizing, psychostimulating and antioxidant effect. Picamilon improves the functional state of the brain and affects cerebral circulation by normalizing tissue metabolism and improving microcirculation.
When taken as a course by patients suffering from VSD, the drug has the following effects:
- increases physical and mental performance;
- reduces headaches;
- normalizes sleep;
- improves memory;
- helps reduce or eliminate tension, fear, and anxiety.
Cerebrovascular disorders have been and remain one of the main causes of mortality and permanent disability [1]. Given the trend toward aging populations throughout the world, there is reason to believe that the number of patients with cerebrovascular pathology will increase [6].
Currently, the main directions of primary and secondary prevention of acute and chronic cerebrovascular disorders have been formulated. There is no doubt about the need to control blood pressure (BP) and glycemia, systematically use antiplatelet drugs, eliminate the impact of modifiable cardiovascular risk factors (smoking, excess alcohol consumption, excessive calorie diet, insufficient level of physical activity) as effective preventive agents [4 , 5]. In this regard, complex-action drugs that have a vasodilating effect on the arterioles and arteries of the brain, as well as having a nootropic effect, are of great interest. One of them is vasobral [2]. The effectiveness of therapy and prevention of cerebrovascular diseases depends not only on medication, but also on patients’ adherence to the systematic implementation of medical recommendations [8]. Factors that have a negative impact on adherence to treatment are patients’ lack of understanding of the purpose of the measures being taken, the occurrence of undesirable effects during therapy, the high cost of treatment, and complex drug dosage regimens, according to patients. It should also be noted that the population is insufficiently informed about the main cardiovascular risk factors and the most important clinical manifestations of various forms of cerebrovascular pathology [3, 7].
These data served as the basis for conducting a study that examined the effectiveness of vasobral in patients with cerebrovascular disorders, as well as factors that may influence patients’ adherence to therapy.
The purpose of the study was to evaluate the effectiveness and tolerability of Vasobral in patients with cerebrovascular pathology by attending physicians and the patients themselves.
Material and methods
The study was based on the results of a survey of 419 neurologists who work in outpatient or inpatient medical care. The survey was conducted at intervals of 4 weeks using a specially designed questionnaire.
There were 1,189 patients under the supervision of doctors, among them 480 patients with chronic cerebral ischemia (CHI) and related conditions, with blockage and stenosis of the precerebral arteries, not leading to cerebral infarction (category I 65 according to ICD-10), blockage and stenosis of the cerebral arteries not leading to cerebral infarction (I 66), other cerebrovascular diseases (I 67.2), cerebral atherosclerosis (I 67.3); in addition, 395 patients with cerebral infarction (I 63) and 314 with vertebrobasilar insufficiency (VBI; G 45.0).
The study did not include patients with severe neurological deficits after an ischemic stroke (IS), who had suffered an IS less than 3 months ago, patients with a hemorrhagic stroke, severe cognitive decline (values on the MMSE scale less than 24 points), with oncological diseases, as well as mental health problems. disorders requiring medication correction.
Vasobral was prescribed 1 tablet (contains 4 mg of alpha-dihydroergocriptine mesylate and 40 mg of caffeine) 2 times a day for 3 months. At the same time, patients, if appropriate, received antiplatelet agents (acetylsalicylic acid, clopidogrel), antihypertensive drugs (ACE inhibitors, calcium channel blockers, diuretics), and antidiabetic drugs.
The questionnaire contained groups of questions aimed at clarifying the following aspects of therapy: physicians' preferences when choosing medications and their combinations for treating patients with cerebrovascular disorders; assessment of the role of vasobral in the combinations and treatment regimens used; determination of the clinical features of diseases for which, in the opinion of interviewed specialists, the use of vasobral is preferable; identifying the strengths and weaknesses of vasobral therapy; assessment of the main clinical effects of treatment with vasobral by patients and doctors; assessment of the tolerability of vasobral prescribed to patients with CCI and similar conditions as part of complex therapy.
The choice of statistical evaluation criteria depended on the type of data distribution and the fulfillment of the condition of equality of variances. The hypothesis about the normality of data distribution was tested (Shapiro-Wilk test).
If the sample data were normally distributed, a comparison was made for equality of variances (Levene's test). If both conditions were met, then t
-Student's t-test or ANOVA model; if not, then its nonparametric alternative (Wilcoxon-Mann-Whitney test) was used.
The same was applied to paired tests when comparing characteristics over time (paired t
-test or Wilcoxon test for paired comparisons). Comparative analysis of qualitative variables was carried out using the χ2 test and Fisher's exact two-tailed test. Statistical analysis was carried out in the SPSS statistical analysis system (IBM SPSS Analytics Software package, USA, version 18.0 for Windows XP).
Results and discussion
When analyzing the choice of therapeutic tactics in the observed patients, it turned out that the vast majority of the surveyed doctors prescribed antihypertensive drugs (71%) and antiplatelet agents (67%) as basic therapy. Statins were used much less frequently (20%).
At the same time, almost all respondents prescribe vasoactive drugs (93%) and neurometabolic agents (93%) to patients with both CCI and IS. Memantine (17%) and acetylcholinesterase inhibitors (13%) were used relatively less frequently, when appropriate indications were available.
The most significant for starting active therapy, according to both patients and doctors, were complaints of dizziness, headache, memory impairment and decreased efficiency of mental work. For patients, the most desirable symptoms were the elimination of symptoms such as dizziness (89%), headache (75%) and tinnitus (56%). Memory impairment and fatigue were the reasons for prescribing therapy less frequently, in 38 and 22% of patients, respectively.
Respondents also noted the need to correct decreased mental performance (18%) and attention problems (15%). It was these disorders, in the opinion of the examined patients, that were the cause of the existing maladaptation and discomfort and, first of all, required elimination.
During the first survey of doctors participating in the study, when asked which drugs, in their opinion, are most effective in treating patients with cerebrovascular disorders (in addition to basic therapy), 19% of respondents named drugs with a vasodilating effect, 14% - drugs neurometabolic action, and 26% preferred combination treatment. In addition, a small proportion of doctors noted a good effect from symptomatic drugs (vestibulolytics, sedatives, hypnotics). Vasobral was named the most effective drug by 22% of surveyed doctors. Patients under the supervision of 20% of doctors did not receive systematic therapy, or the surveyed specialists did not have the opportunity to indicate the group of drugs that had the maximum positive effect.
When repeating the survey, it turned out that the number of doctors who prefer to prescribe vasodilators, neurometabolic drugs and their combinations decreased slightly (to 18, 13 and 24%, respectively); this dynamics was not significant compared to the result of the first survey. At the same time, the number of doctors preferring to prescribe Vasobral increased significantly - up to 28% ( p
<0.05 compared to the first survey). The indicated dynamics, as was established as a result of a detailed survey of respondents, turned out to be associated with the positive effect of the use of the drug, as well as its good tolerability. An increase in the number of patients on whose condition Vasobral had a positive effect was noted both due to patients who had previously taken neurometabolic drugs as monotherapy, and patients who had not previously received systematic therapy.
Of interest is that as treatment continued, from 8 to 30% ( p
<0.001) the number of doctors who noted signs of the nootropic effect of vasobral increased: improved memory, ability to concentrate, restoration of mental performance, etc. It was this circumstance, according to the respondents, that turned out to be one of the most important factors increasing adherence to the prescription of this drug.
The surveyed doctors noted the high efficiency and safety of use, good tolerability of the course of treatment (18%), as well as a wide range of indications and clinical effects (17%) as particularly valuable properties of vasobral. In addition, important factors of social significance for the majority of patients were the almost constant availability of the drug in the pharmacy chain (70%) and its affordable price (69%).
According to a significant part of doctors, the multidirectional action of vasobral was also important, which simultaneously affects a number of clinical manifestations of the disease that are significant for the patient, in particular with VBI (dizziness, tinnitus, etc.). Patients often o (75% of patients, p
=0.013), “memory improved” (65%,
p
=0.015).
p
= 0.002), memory (65%,
p
improved with the use of vasobral ; in addition, many doctors noted that their patients’ performance increased (63 %,
p
=0.003) and the ability to concentrate (58%,
p
=0.003).
The following assessments were less common: “it became easier to think” (48%, p
<0.001) and “there was more strength” (46%,
p
= 0.035), although their share also significantly increased.
When assessing the dynamics of the use of Vasobral by doctors after the first and repeated testing, it turned out that for CCI and related conditions, the number of its prescriptions increased by 36% ( p
<0.001).
by 18% ( p
<0.001), in particular with a predominance of vestibular and labyrinthine disorders in the clinical picture (dizziness, tinnitus, balance disorders).
A smaller increase in the number of Vasobral prescriptions was observed with the consequences of AI - 10%, but the dynamics were also significant ( p
<0.01).
When analyzing the relationship between the achieved effect of treatment with vasobral and the characteristics of the clinical picture of vascular brain damage, it turned out that the maximum effect was observed in patients with initial manifestations of CCI, which did not significantly affect their work activity and social adaptation, as well as in patients with memory loss within the lungs cognitive impairment who have not previously suffered episodes of acute cerebral ischemia. A pronounced positive effect of vasobral was also observed in patients with VBI, as well as in the combination of CCI with migraine, tension headaches and vegetative-vascular disorders. The positive effect was significantly more frequent ( p
<0.05) was observed in younger patients.
There were no differences in the effectiveness of Vasobral depending on the level of blood pressure at the time of inclusion in the study, the presence of previously diagnosed arterial hypertension, arterial hypotension, type 2 diabetes mellitus or asthenic syndrome.
When assessing the possible undesirable effects of Vasobral, the most often during the first testing, the respondent doctors noted the following: decreased blood pressure - 55 (13.1%) people, increased blood pressure - 37 (8.8%), tachycardia - 27 (6.4%), dyspepsia - 22 (5.3%), headache - 20 (4.8%).
During repeated testing, doctors most often noted the following undesirable effects of vasobral: the ability to lower blood pressure - 43 (10.3%) respondents, increase blood pressure - 29 (6.9%), cause tachycardia - 26 (6.2%), dyspepsia - 22 (5.3%), headache - 13 (3.1%), sleep disturbances - 13 (3.1%). Some doctors (16; 3.8%) expressed regret about the lack of injectable forms of the drug.
It should be noted that the presence of a number of nonspecific side effects did not have a significant impact on patients’ adherence to treatment and was not a reason for refusing to continue treatment.
The data obtained in this work confirm the point of view about the effectiveness and good tolerability of vasobral in vascular diseases of the brain. The rarity of clinically significant adverse effects largely determined patient adherence to such therapy. For doctors, an important basis for further prescribing vasobral was their personal experience, indicating an improvement in cognitive functions in patients when using the drug. Vasobral therapy was most effective for mild cognitive impairment due to CCI. This allows us to consider vasobral as the main drug in this group of patients (with mandatory basic preventive therapy), while in patients with more pronounced focal and cognitive deficits, vasobral should be used as part of complex therapy.
