Antithrombotic Therapy for Peripheral Artery Disease

Hussain MA, Al-Omran M, Creager MA, Anand SS, Verma S, Bhatt DL.
Antithrombotic Therapy for Peripheral Artery Disease: Recent Advances. J Am Coll Cardiol 2018;71:2450-2467.

The following are key points to remember from this review on recent advances in antithrombotic therapy for patients with peripheral artery disease (PAD):

  1. PAD affects over 200 million people globally and is a cause of significant morbidity, mortality, and disability due to limb loss.
  2. Despite the fact that secondary prevention with antithrombotic therapy is a mainstay of treatment to prevent adverse cardiovascular events, PAD patients are often undertreated with antithrombotic agents.
  3. Data on antithrombotic therapy for stable PAD are largely derived from subanalyses of randomized trials that enrolled patients with various manifestations of atherosclerosis, including coronary disease, cerebrovascular disease, and PAD.
  4. Currently, there is no definitive evidence for the efficacy of aspirin in patients with asymptomatic PAD. The guidelines vary in their treatment recommendations for patients with asymptomatic PAD. The American Heart Association/American College of Cardiology PAD guideline recommends antiplatelet therapy as reasonable if the ankle-brachial index is ≤0.90; the European Society of Cardiology guideline recommends against routine antiplatelet therapy in asymptomatic patients; and the Society for Vascular Surgery guideline provides no specific recommendations for this.
  5. Patients with symptomatic PAD should be treated with antithrombotic therapy to reduce cardiovascular risk. Single antiplatelet therapy with either aspirin or clopidogrel is recommended.
  6. Patients who undergo revascularization for PAD should be prescribed lifelong antithrombotic therapy. With respect to surgical revascularization, aspirin, clopidogrel, and rivaroxaban plus aspirin are all reasonable strategies.
  7. With respect to endovascular revascularization (angioplasty with or without stenting), the standard of care in the absence of high-quality evidence is to treat patients with dual antiplatelet therapy for 1-6 months after the procedure.
  8. There is insufficient evidence to recommend tailored antithrombotic regimens in patients undergoing conventional balloon angioplasty versus drug-eluting balloon angioplasty or bare-metal versus drug-eluting stenting.
  9. The initial treatment period after revascularization should be followed by lifelong single antiplatelet therapy (aspirin or clopidogrel), or potentially rivaroxaban plus aspirin, given data from the COMPASS trial.
  10. An evidenced-based approach to PAD patients is essential to achieve optimal outcomes, weighing cardiovascular and limb benefits against potential bleeding risks.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine

Keywords: Angioplasty, Balloon, Coronary, Ankle Brachial Index, Anticoagulants, Aspirin, Atherosclerosis, Cardiovascular Diseases, Cerebrovascular Disorders, Fibrinolytic Agents, Myocardial Revascularization, Peripheral Arterial Disease, Platelet Aggregation Inhibitors, Risk Factors, Secondary Prevention, Standard of Care, Vascular Diseases

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