Dual Antiplatelet Therapy for Coronary and Peripheral Arterial Disease

Abstract Introduction Guideline recommendations for antithrombotic (antiplatelet and anticoagulant) therapy during and after endovascular intervention are patchy and conflicted, in part due to a lack of evidence. The aim of this systematic review was to examine the antithrombotic specifications in randomised trials for peripheral arterial endovascular intervention. Method This review was conducted according to PRISMA guidelines. Randomised trials including participants with peripheral arterial disease undergoing endovascular arterial intervention were included. Trial methods were assessed to determine whether an antithrombotic protocol had been specified, its completeness, and the agent(s) prescribed. Antithrombotic protocols were classed as periprocedural (preceding/during intervention), immediate postprocedural (up to 14 days following intervention) and maintenance postprocedural (therapy continuing beyond 14 days). Trials were stratified according to type of intervention. Result Ninety-four trials were included. Only 29% of trials had complete periprocedural antithrombotic protocols, and 34% had complete post-procedural protocols. In total, 64 different periprocedural protocols, and 51 separate postprocedural protocols were specified. Antiplatelet monotherapy and unfractionated heparin were the most common choices of regimen in the periprocedural setting, and dual antiplatelet therapy (55%) was most commonly utilised postprocedure. There is an increasing tendency to use dual antiplatelet therapy with time or for drug-coated technologies. Conclusion Randomised trials comparing different types of peripheral endovascular arterial intervention have a high level of heterogeneity in their antithrombotic regimens, and there has been an increasing tendency to use dual antiplatelet therapy over time. Antiplatelet regimes need to be standardised in trials comparing endovascular technologies. Take-home message To determine the benefits of any endovascular intervention within a randomised trial, antithrombotic regimens should be standardised to prevent confounding. This systematic review demonstrates a high level of heterogeneity of antithrombotic prescribing in randomised trials of endovascular intervention, and an increasing tendency to utilise dual antiplatelet therapy, despite a lack of evidence of benefit, but an increased risk of harm.

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Prolonged vs Short Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With or Without Peripheral Arterial Disease

JAMA Cardiology ◽

10.1001/jamacardio.2016.2811 ◽

2016 ◽

Vol 1 (7) ◽

pp. 795 ◽

Cited By ~ 29

Author(s):

Anna Franzone ◽

Raffaele Piccolo ◽

Giuseppe Gargiulo ◽

Sara Ariotti ◽

Marcello Marino ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Peripheral Arterial Disease ◽

Antiplatelet Therapy ◽

Short Duration ◽

Dual Antiplatelet Therapy ◽

Coronary Intervention ◽

Arterial Disease ◽

Percutaneous Coronary ◽

Peripheral Arterial

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Rivaroxaban Plus Aspirin Versus Standard Dual Antiplatelet Therapy Following Angioplasty for Lower Extremity Peripheral Arterial Disease in Patients With Critical Limb Ischemia and Claudication (RIVAL-PAD): 12-Month Results of a Randomized Trial

Journal of Vascular Surgery ◽

10.1016/j.jvs.2018.06.135 ◽

2018 ◽

Vol 68 (3) ◽

pp. e67

Author(s):

Prasad Jetty ◽

Dalibor Kubelik ◽

Sudhir Nagpal ◽

Andrew Hill ◽

George Hajjar ◽

...

Keyword(s):

Peripheral Arterial Disease ◽

Lower Extremity ◽

Randomized Trial ◽

Antiplatelet Therapy ◽

Critical Limb Ischemia ◽

Dual Antiplatelet Therapy ◽

Limb Ischemia ◽

Arterial Disease ◽

Peripheral Arterial

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Extended Duration Dual Antiplatelet Therapy After Coronary Stenting Among Patients With Peripheral Arterial Disease

JACC Cardiovascular Interventions ◽

10.1016/j.jcin.2017.02.013 ◽

2017 ◽

Vol 10 (9) ◽

pp. 942-954 ◽

Cited By ~ 24

Author(s):

Eric A. Secemsky ◽

Robert W. Yeh ◽

Dean J. Kereiakes ◽

Donald E. Cutlip ◽

P. Gabriel Steg ◽

...

Keyword(s):

Peripheral Arterial Disease ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Arterial Disease ◽

Coronary Stenting ◽

Extended Duration ◽

Peripheral Arterial

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Association of dual-antiplatelet therapy with reduced major adverse cardiovascular events in patients with symptomatic peripheral arterial disease

Journal of Vascular Surgery ◽

10.1016/j.jvs.2015.01.051 ◽

2015 ◽

Vol 62 (1) ◽

pp. 157-165.e1 ◽

Cited By ~ 43

Author(s):

Ehrin J. Armstrong ◽

David R. Anderson ◽

Khung-Keong Yeo ◽

Gagan D. Singh ◽

Heejung Bang ◽

...

Keyword(s):

Peripheral Arterial Disease ◽

Antiplatelet Therapy ◽

Cardiovascular Events ◽

Dual Antiplatelet Therapy ◽

Arterial Disease ◽

Major Adverse Cardiovascular Events ◽

Peripheral Arterial

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Short-Term Clinical Outcomes of Single Versus Dual Antiplatelet Therapy after Infrainguinal Endovascular Treatment for Peripheral Arterial Disease

Journal of Clinical Medicine ◽

10.3390/jcm9113515 ◽

2020 ◽

Vol 9 (11) ◽

pp. 3515

Author(s):

Jetty Ipema ◽

Rutger H. A. Welling ◽

Olaf J. Bakker ◽

Reinoud P. H. Bokkers ◽

Jean-Paul P. M. de Vries ◽

...

Keyword(s):

Peripheral Arterial Disease ◽

Endovascular Treatment ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Arterial Disease ◽

Bleeding Complications ◽

Major Adverse Cardiovascular Events ◽

Below The Knee ◽

Peripheral Arterial ◽

Male Rate

After infrainguinal endovascular treatment for peripheral arterial disease (PAD), it is uncertain whether single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) should be preferred. This study investigated major adverse limb events (MALE) and major adverse cardiovascular events (MACE) between patients receiving SAPT and DAPT. Patient data from three centers in the Netherlands were retrospectively collected and analyzed. All patients treated for PAD by endovascular revascularization of the superficial femoral, popliteal, or below-the-knee (BTK) arteries and who were prescribed acetylsalicylic acid or clopidogrel, were included. End points were 1-, 3-, and 12-month MALE and MACE, and bleeding complications. In total, 237 patients (258 limbs treated) were included, with 149 patients receiving SAPT (63%) and 88 DAPT (37%). No significant differences were found after univariate and multivariate analyses between SAPT and DAPT on 1-, 3-, and 12-month MALE and MACE, or bleeding outcomes. Subgroup analyses of patients with BTK treatment showed a significantly lower 12-month MALE rate when treated with DAPT (hazard ratio 0.33; 95% confidence interval 0.12–0.95; p = 0.04). In conclusion, although patient numbers were small, no differences were found between SAPT and DAPT regarding MALE, MACE, or bleeding complications. DAPT should, however, be considered over SAPT for the subgroup of patients with below-the-knee endovascular treatment.

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