A comprehensive review on antithrombotic therapy for peripheral artery disease

Gupta, Renu; Majumdar, Monica; Imran, Rabbia

doi:10.1053/j.semvascsurg.2022.04.004

Cited by 9 publications

(6 citation statements)

References 52 publications

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“… 25 Most efforts to prevent thrombosis after surgery for PAD rely on standard “one‐size‐fits‐all” recommendations, which are then inconsistently, and somewhat subjectively, altered at the discretion of the surgeon based on intervention subtype or concomitant risk factors. 13 …”

Section: Discussionmentioning

confidence: 99%

“… 9 , 10 Despite our understanding of the molecular biology, there is no level 1A evidence supporting the use of multimodal antithrombotic therapy for PAD. 11 , 12 , 13 Most recommendations are derived from subgroup analysis of randomized trials for patients with coronary and cerebrovascular disease. 13 , 14 Prior trials examining the use of anticoagulation medications in addition to antiplatelet therapy after revascularization have lacked efficacy, found an unacceptable bleeding risk, or been criticized for a lack of generalizability.…”

mentioning

confidence: 99%

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Predicting Arterial Thrombotic Events Following Peripheral Revascularization Using Objective Viscoelastic Data

Majumdar

Hall

Feldman

et al. 2023

JAHA

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Background Peripheral artery disease is endemic in our globally aging population, with >200 million affected worldwide. Graft/stent thrombosis after revascularization is common and frequently results in amputation, major adverse cardiovascular events, and cardiovascular mortality. Optimizing medications to decrease thrombosis is of paramount importance; however, limited guidance exists on how to use and monitor antithrombotic therapy in this heterogeneous population. Thromboelastography with platelet mapping (TEG‐PM) provides comprehensive coagulation metrics and may be integral to the next stage of patient‐centered thrombophrophylaxis. This prospective study aimed to determine if TEG‐PM could predict subacute graft/stent thrombosis following lower extremity revascularization, and if objective cut point values could be established to identify those high‐risk patients. Methods and Results We conducted a single‐center prospective observational study of patients undergoing lower extremity revascularization. Patients were followed up for the composite end point postoperative graft/stent thrombosis at 1 year. TEG‐PM analysis of the time point before thrombosis in the event group was compared with the last postoperative visit in the nonevent group. Cox proportional hazards analysis examined the association of TEG‐PM metrics to thrombosis. Cut point analysis explored the predictive capacity of TEG‐PM metrics for those at high risk. A total of 162 patients were analyzed, of whom 30 (18.5%) experienced graft/stent thrombosis. Patients with thrombosis had significantly greater platelet aggregation (79.7±15.7 versus 58.5±26.4) and lower platelet inhibition (20.7±15.6% versus 41.1±26.6%) (all P <0.01). Cox proportional hazards analysis revealed that for every 1% increase in platelet aggregation, the hazard of experiencing an event during the study period increased by 5% (hazard ratio, 1.05 [95% CI, 1.02–1.07]; P <0.01). An optimal cut point of >70.8% platelet aggregation and/or <29.2% platelet inhibition identifies those at high risk of thrombosis with 87% sensitivity and 70% to 71% specificity. Conclusions Among patients undergoing lower extremity revascularization, increased platelet reactivity was predictive of subacute postoperative graft/stent thrombosis. On the basis of the cut points of >70.8% platelet aggregation and <29.2% platelet inhibition, consideration of an alternative or augmented antithrombotic regimen for high‐risk patients may decrease the risk of postoperative thrombotic events.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Predicting Arterial Thrombotic Events Following Peripheral Revascularization Using Objective Viscoelastic Data

Majumdar

Hall

Feldman

et al. 2023

JAHA

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“…One of the major challenges of LE-PAD treatment is the significant variability in patient presentation, ranging from asymptomatic to presenting with intermittent claudication, skin ulceration, or gangrene. 16,17 Moreover, the pattern of disease progression is complicated by several comorbidities. Several clinical studies have provided evidence of the benefits of antithrombotic therapy for patients with PAD and have proposed management strategies for them.…”

Section: Discussionmentioning

confidence: 99%

Comparison of rivaroxaban-based dual antithrombotic and antiplatelet therapies for symptomatic patients with lower-extremity peripheral artery disease post-revascularization: a retrospective cohort study

Ji,

Wang,

et al. 2023

Therapeutic Advances in Chronic Disease

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Background: Patients with symptomatic lower-extremity peripheral artery disease (LE-PAD) are prone to serious cardiovascular and limb events. Few studies have evaluated the effect of rivaroxaban-based dual antithrombotic therapy in high-risk patients with LE-PAD in Asian populations. Objectives: To investigate the efficacy and safety of rivaroxaban-based dual antithrombotic therapy in symptomatic patients with LE-PAD. Design: Retrospective cohort study. Methods: This study included patients with LE-PAD treated at the Nanjing Drum Tower Hospital from 1 January 2018 to 31 December 2021. These participants were divided into antiplatelet (APT) or antiplatelet therapy combined with rivaroxaban (RAPT) groups. The efficacy outcomes in this study were the occurrence of major adverse cardiovascular events (MACE), including myocardial infarction, ischemic stroke, or death from cardiovascular causes, and major adverse limb events (MALE), including urgent revascularization, acute limb ischemia, and major amputation. The safety outcomes included major and clinically relevant non-major (CRNM) bleeding. Patients were followed up until the time of death or the end of the study (31 March 2023). Results: We included 1144 patients with LE-PAD (APT: 502 patients; RAPT: 642 patients). The RAPT group had a lower risk of primary composite efficacy outcomes [hazard ratio (HR): 0.40] and a nonsignificant increase in major bleeding risk (HR: 2.33) than the APT group. The RATP group also had a significantly lower risk of secondary efficacy outcomes, including ischemic stroke (HR: 0.41), myocardial infarction (HR: 0.31), cardiovascular death (HR: 0.40), and MALE (HR: 0.65), than the APT group. The CRNM bleeding incidence varied between the two groups (HR: 3.96). Moreover, no significant interactions were observed between the subgroups and treatment groups in the composite efficacy analysis. Conclusion: Rivaroxaban-based dual antithrombotic therapy significantly reduced the occurrence of MACE in patients with LE-PAD without increasing major bleeding events. High-risk patients benefited from the dual antithrombotic therapy.

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“…Low molecular weight heparins are less likely to do so. Bleeding episodes constitute the main adverse effects of the DOACs [ 10 , 11 ].…”

Section: Preamblementioning

confidence: 99%

Antithrombotic and antiplatelet effects of plant-derived compounds: a great utility potential for primary, secondary, and tertiary care in the framework of 3P medicine

et al. 2022

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Thromboembolism is the third leading vascular disease, with a high annual incidence of 1 to 2 cases per 1000 individuals within the general population. The broader term venous thromboembolism generally refers to deep vein thrombosis, pulmonary embolism, and/or a combination of both. Therefore, thromboembolism can affect both – the central and peripheral veins. Arterial thromboembolism causes systemic ischemia by disturbing blood flow and oxygen supply to organs, tissues, and cells causing, therefore, apoptosis and/or necrosis in the affected tissues. Currently applied antithrombotic drugs used, e.g. to protect affected individuals against ischemic stroke, demonstrate significant limitations. For example, platelet inhibitors possess only moderate efficacy. On the other hand, thrombolytics and anticoagulants significantly increase hemorrhage. Contextually, new approaches are extensively under consideration to develop next-generation antithrombotics with improved efficacy and more personalized and targeted application. To this end, phytochemicals show potent antithrombotic efficacy demonstrated in numerous in vitro, ex vivo, and in vivo models as well as in clinical evaluations conducted on healthy individuals and persons at high risk of thrombotic events, such as pregnant women (primary care), cancer, and COVID-19-affected patients (secondary and tertiary care). Here, we hypothesized that specific antithrombotic and antiplatelet effects of plant-derived compounds might be of great clinical utility in primary, secondary, and tertiary care. To increase the efficacy, precise patient stratification based on predictive diagnostics is essential for targeted protection and treatments tailored to the person in the framework of 3P medicine. Contextually, this paper aims at critical review toward the involvement of specific classes of phytochemicals in antiplatelet and anticoagulation adapted to clinical needs. The paper exemplifies selected plant-derived drugs, plant extracts, and whole plant foods/herbs demonstrating their specific antithrombotic, antiplatelet, and fibrinolytic activities relevant for primary, secondary, and tertiary care. One of the examples considered is antithrombotic and antiplatelet protection specifically relevant for COVID-19-affected patient groups.

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A comprehensive review on antithrombotic therapy for peripheral artery disease

Cited by 9 publications

References 52 publications

Predicting Arterial Thrombotic Events Following Peripheral Revascularization Using Objective Viscoelastic Data

Predicting Arterial Thrombotic Events Following Peripheral Revascularization Using Objective Viscoelastic Data

Comparison of rivaroxaban-based dual antithrombotic and antiplatelet therapies for symptomatic patients with lower-extremity peripheral artery disease post-revascularization: a retrospective cohort study

Antithrombotic and antiplatelet effects of plant-derived compounds: a great utility potential for primary, secondary, and tertiary care in the framework of 3P medicine

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