Platelet aggregation inhibitor prescription for newly diagnosed peripheral arterial disease in the Netherlands: a cohort study

Abstract

ObjectivesPharmacological treatment of peripheral arterial disease (PAD) comprises of antiplatelet therapy (APT), blood pressure control and cholesterol optimisation. Guidelines provide class-I recommendations on the prescription, but there are little data on the actual prescription practices. Our study provides insight into the prescription of medication among patients with PAD in the Netherlands and reports a ‘real-world’ patient journey through primary and secondary care.DesignWe conducted a cohort study among patients newly diagnosed with PAD between 2010 and 2014.SettingData were obtained from the PHARMO Database Network, a population-based network of electronic pharmacy, primary and secondary healthcare setting records in the Netherlands. The source population for this study comprised almost 1 million individuals.Participants‘Newly diagnosed’ was defined as a recorded International Classification of Primary Care code for PAD, a PAD-specific WCIA examination code or a diagnosis recorded as free text episode in the general practitioner records with no previous PAD diagnosis record and no prescription of P2Y12 inhibitors or aspirin the preceding year. The patient journey was defined by at least 1 year of database history and follow-up relative to the index date.ResultsBetween 2010 and 2014, we identified 3677 newly diagnosed patients with PAD. Most patients (91%) were diagnosed in primary care. Almost half of all patients (49%) had no APT dispensing record. Within this group, 33% received other anticoagulant therapy (vitamin K antagonist or direct oral anticoagulant). Mono-APT was dispensed as aspirin (40% of patients) or P2Y12 inhibitors (2.5% of patients). Dual APT combining aspirin with a P2Y12 inhibitor was dispensed to 8.5% of the study population.ConclusionHalf of all patients with newly diagnosed PAD are not treated conforming to (international) guideline recommendations on thromboembolism prevention through APT. At least 33% of all patients with newly diagnosed PAD do not receive any antithrombotic therapy. Evaluation and improvement of APT prescription and thereby improved prevention of (secondary) cardiovascular events is warranted.

Antithrombotic Therapy in Patients with Peripheral Artery Disease: A Focused Review on Oral Anticoagulation

“…Despite these recommendations, an important proportion of patients with newly diagnosed PAD are not treated conforming to guidelines, and at least 33% of these patients do not receive any antithrombotic therapy [51]. In addition, although medical prevention of PAD complications has increased over time, a non-negligible proportion of patients will still suffer adverse events during the follow-up, particularly those related to lower extremities such as major amputations [52].…”

Endothelial cell dysfunction: Implications for the pathogenesis of peripheral artery disease

“…As described earlier PAD is associated with dysregulated platelet activation and coagulation, which could precipitate major thrombotic events, observed not only in large vessel disease, but also in small vessels with microthrombi resulting in reduced tissue perfusion. Although current guidelines recommend the use of antiplatelet and antithrombotic medication to reduce the risk of MI or stroke ( 4 , 99 – 101 ) there is a significant lack of guideline adherence ( 136 ), especially for newly-diagnosed PAD patients ( 137 ). Generally speaking, aspirin and clopidogrel are the two most studied antiplatelet medications.…”