Antiplatelet and Anticoagulant Therapies in Symptomatic Peripheral Artery Disease
A 63-year-old woman with a history of ischemic stroke 3 years prior, coronary artery disease (CAD) with a remote drug eluting stent placement to the right coronary artery and peripheral artery disease (PAD) with typical claudication after walking 3 blocks presents to your outpatient clinic. She denies resting foot pain, non-healing ulcers or loss of motor or sensory functions involving the limbs. Her additional risk factors include type II diabetes mellitus, hypertension, dyslipidemia and 25 pack-years of tobacco use. She denies alcohol or illicit drug use. Family history is notable for premature CAD in multiple members.
Current medications include aspirin 81 mg daily, metoprolol 50 mg daily, lisinopril 40 mg daily, atorvastatin 80 mg daily, cilostazol 100 mg twice daily and metformin 1000 mg twice daily.
Cardiac exam is within normal limits. Vascular exam is notable for bilateral carotid bruits, symmetrically decreased 1+ dorsalis pedis and posterior tibial artery pulses and otherwise intact peripheral pulses throughout. Feet are warm with rapid capillary refill and preserved motor and sensory functions. There are no ulcerations and no tissue or hair loss.
Ankle-brachial indices are 0.80 on the right and 0.78 on the left.
The addition of which of the following antiplatelet/anticoagulant agents is most appropriate to reduce both cardiovascular and limb-related events in this patient?