Antithrombotic treatment in peripheral artery disease

Abstract

This review treats antithrombotic use for peripheral arterial disease (PAD). In asymptomatic patients, there are no scientific data to support single antiplatelet therapy (SAPT) for primary prophylaxis. In symptomatic PAD, SAPT with aspirin or clopidogrel is indicated. The efficacy of aspirin is controversial. Clopidogrel may be preferred over aspirin. Ticagrelor is not superior to clopidogrel in reducing major adverse cardiovascular events and major adverse limb events, but lowers the risk of ischaemic stroke. In symptomatic PAD, dual antiplatelet therapy (DAPT) with clopidogrel and aspirin does not provide benefit over SAPT with aspirin alone and is associated with increased risk of major bleeding. DAPT with ticagrelor 60 mg b. i. d. and aspirin provides a significant major adverse cardiovascular events reduction in symptomatic PAD patients and may be considered in PAD patients with prior myocardial infarction. The use of a new thrombin receptor antagonist, vorapaxar, on top of SAPT or DAPT with aspirin and/or clopidogrel, reduces the risk of acute limb ischaemia and peripheral artery revascularization in patients with symptomatic PAD, at the cost of an increased risk for bleeding. Rivaroxaban (2.5 mg b. i. d.) plus aspirin (100 mg daily) is the first antithrombotic association that proved significant benefit for PAD patients, in terms of strong endpoints - total mortality and cardiovascular mortality. Therefore, this association shows the strongest evidence for secondary prevention of symptomatic PAD patients. In PAD patients undergoing percutaneous peripheral interventions, at least four weeks of DAPT with aspirin and clopidogrel is recommended after infrainguinal stent implantation. Stenting below-the-knee arteries is often followed by a longer period of DAPT, but no specific evidence is available. Anticoagulation is mandatory to prevent arterial occlusion during radial or brachial invasive procedures. The strategy includes use of unfractioned heparin, bivalirudin or enoxaparin. Vitamin K antagonists may be considered after autologous vein infrainguinal bypass.

Is Long-Term Anticoagulation Required after Stent Placement for Benign Superior Vena Cava Syndrome?

“…However, anticoagulation is recommended after iliocaval venous stent placement (12). Regarding arterial stents, this study also correlates with prior studies looking at anticoagulation and coronary and superficial femoral arteries stents, in which no advantage was identified (23)(24)(25).…”

"High-dose statin prior to primary percutaneous coronary intervention reduces oxidative stress burden in patients with acute ST-elevation myocardial infarction "

“…Only patients with successful reperfusion were included in the study. All patients were pretreated with antithrombotic medication according to current recommendations [2,3,31]. All demographic, clinical, paraclinical and intraprocedural data were stored in the Departments' structured database for future comparing [32,33].…”

“…Cardiovascular diseases are the leading cause of mortality and morbidity worldwide [1]. Acute ST-elevation myocardial infarction (STEMI) is associated with total coronary occlusion and subsequent myocardial necrosis.…”

ESVM Guideline on peripheral arterial disease

“…A primary meta-analysis carried out by the Antithrombotic Trialists' Collaboration failed to detect a significant decrease in cardiovascular events in PAD patients who were taking ASA and who presented no further vascular lesions in other organs. So, while there are conclusive study results regarding the secondary prevention of cardiac and cerebrovascular events in patients with PAD with antiplatelet agents other than aspirin, the data base regarding the primary prevention of peripheral arterial events is insufficient and in part contradictory [199][200][201].…”

“…In patients with symptomatic PAD, platelet aggregation inhibitors are indicated for the secondary prevention of cardiovascular events. stroke, cardiovascular mortality) nor reduced rates of major amputations compared to placebo-treated patients [17,200,201]. Amongst other reasons, the authors attributed this result to the wide application of statins in this high-risk group [167].…”