Antithrombotic Therapy in Lower Extremity Artery Disease

2020 ◽  
Vol 18 (3) ◽  
pp. 215-222 ◽  
Author(s):  
Mislav Vrsalovic ◽  
Victor Aboyans
Keyword(s):  
Lower Extremity ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Cardiovascular Events ◽  
Cardiovascular Outcomes ◽  
Lower Limbs ◽  
Stent Type ◽  
Increased Risk ◽  
Artery Disease ◽  
Lower Extremity Artery Disease

Lower extremity artery disease (LEAD) is a marker of a more advanced atherosclerotic process often affecting multiple vascular beds beyond the lower limbs, with a consequent increased risk for all-cause and cardiovascular mortality. Antithrombotic therapy is the cornerstone of management of these patients to prevent ischaemic cardiovascular and limb events and death. In patients with symptomatic LEAD, the efficacy of aspirin has been established long ago for the prevention of cardiovascular events. In the current guidelines, clopidogrel may be preferred over aspirin following its incremental ability to prevent cardiovascular events, while ticagrelor is not superior to clopidogrel in reducing cardiovascular outcomes. Dual antiplatelet therapy (DAPT, aspirin with clopidogrel) is currently recommended for at least 1 month after endovascular interventions irrespective of the stent type. Antiplatelet monotherapy is recommended after infra-inguinal bypass surgery, and DAPT may be considered in below-the-knee bypass with a prosthetic graft. In symptomatic LEAD, the addition of anticoagulant (vitamin K antagonists) to antiplatelet therapy increased the risk of major and life-threatening bleeding without benefit regarding cardiovascular outcomes. In a recent trial, low dose of direct oral anticoagulant rivaroxaban plus aspirin showed promising results, not only to reduce death and major cardiovascular events, but also major limb events including amputation. Yet, this option should be considered especially in very high risk patients, after considering also the bleeding risk. Despite all the evidence accumulated since >40 years, many patients with LEAD remain undertreated and deserve close attention and implementation of guidelines advocating the use of antithrombotic therapies, tailored according to their level of risk.

scholarly journals Antithrombotic Therapy for Atherosclerotic Cardiovascular Disease Risk Mitigation in Patients With Coronary Artery Disease and Diabetes Mellitus

Circulation ◽  
2020 ◽  
Vol 142 (22) ◽  
pp. 2172-2188
Author(s):  
Davide Capodanno ◽  
Dominick J. Angiolillo
Keyword(s):  
Diabetes Mellitus ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Secondary Prevention ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Cardiovascular Events ◽  
Thrombotic Risk ◽  
Increased Risk ◽  
Artery Disease

Patients with diabetes mellitus (DM) are characterized by enhanced thrombotic risk attributed to multiple mechanisms including hyperreactive platelets, hypercoagulable status, and endothelial dysfunction. As such, they are more prone to atherosclerotic cardiovascular events than patients without DM, both before and after coronary artery disease (CAD) is established. In patients with DM without established CAD, primary prevention with aspirin is not routinely advocated because of its increased risk of major bleeding that largely offsets its ischemic benefit. In patients with DM with established CAD, secondary prevention with antiplatelet drugs is an asset of pharmacological strategies aimed at reducing the risk of atherosclerotic cardiovascular events and their adverse prognostic consequences. Such antithrombotic strategies include single antiplatelet therapy (eg, with aspirin or a P2Y 12 inhibitor), dual antiplatelet therapy (eg, aspirin combined with a P2Y 12 inhibitor), and dual-pathway inhibition (eg, aspirin combined with the vascular dose of the direct oral anticoagulant rivaroxaban) for patients with chronic ischemic heart disease, acute coronary syndromes, and those undergoing percutaneous coronary intervention. Because of their increased risk of thrombotic complications, patients with DM commonly achieve enhanced absolute benefit from more potent antithrombotic approaches compared with those without DM, which most often occurs at the expense of increased bleeding. Nevertheless, studies have shown that when excluding individuals at high risk for bleeding, the net clinical benefit favors the use of intensified long-term antithrombotic therapy in patients with DM and CAD. Several studies are ongoing to establish the role of novel antithrombotic strategies and drug formulations in maximizing the net benefit of antithrombotic therapy for patients with DM. The scope of this review article is to provide an overview of current and evolving antithrombotic strategies for primary and secondary prevention of atherosclerotic cardiovascular events in patients with CAD and DM.

Patients’ radiation doses during percutaneous endovascular procedures in arteries of the lower limbs

VASA ◽  
2019 ◽  
Vol 48 (2) ◽  
pp. 167-174 ◽  
Author(s):  
Vinko Boc ◽  
Anja Boc ◽  
Urban Zdešar ◽  
Aleš Blinc
Keyword(s):  
Lower Extremity ◽  
Lower Limbs ◽  
Therapeutic Interventions ◽  
Radiation Doses ◽  
Arterial Lesion ◽  
Dose Area Product ◽  
Anatomical Region ◽  
Artery Disease ◽  
Area Product ◽  
Lower Extremity Artery Disease

Abstract. Background: Percutaneous endovascular revascularisation interventions are increasingly used in treatment of lower extremity artery disease and may expose patients to substantial radiation. Patients and methods: Dose-area product (DAP) was retrospectively analysed in 1063 consecutive interventions performed in adult patients with lower extremity artery disease in a single tertiary medical centre. Differences between procedure types, stratified according to anatomical region and arterial lesion complexity were evaluated. Results: Median DAP for diagnostic interventions was 35.6 (15.0–52.4) Gy cm2 in aorto-below-knee arteriography and 3.2 (2.0–4.5) Gy cm2 in ipsilateral femoral arteriography (p < 0.001). For angioplasty without stenting, median DAP was 53.4 (28.6–87.4) Gy cm2 for pelvic interventions vs. 5.9 (4.3–8.6) Gy cm2 for antegrade ipsilateral femoropopliteal interventions (p < 0.001). For stenting, median DAP was 54.9 (32.5–91.2) Gy cm2 for pelvic interventions vs. 8.3 (6.0–12.3) Gy cm2 for antegrade ipsilateral femoropopliteal interventions (p < 0.001). Inside the same anatomical region, diagnostic interventions were associated with significantly lower DAP than therapeutic interventions. Stenting vs no stenting increased DAP values only in antegrade ipsilateral femoropopliteal interventions (8.3 (6.0–12.3) vs 5.9 (4.3–8.6) Gy cm2 (p < 0.001). Arterial lesion complexity affected DAP values only in antegrade ipsilateral femoropopliteal therapeutic interventions. Conclusions: The most important factor influencing patients’ radiation doses was the anatomical region. Pelvic interventions were associated with 6–11-times higher DAP values than femoropopliteal interventions with antegrade ipsilateral approach. Stenting and complexity of lesions increased DAP only in antegrade ipsilateral femoropopliteal interventions.

Association Of Lipoprotein(A) With Lower Extremity Artery Disease And Cardiovascular Outcomes After Peripheral Revascularization

2019 ◽  
Vol 287 ◽  
pp. e57-e58
Author(s):  
N. Tmoyan ◽  
M. Ezhov ◽  
E. Klesareva ◽  
M. Afanasieva ◽  
O. Afanasieva ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Cardiovascular Outcomes ◽  
Lipoprotein A ◽  
Artery Disease ◽  
Lower Extremity Artery Disease

scholarly journals Artificial-Intelligence-Assisted Discovery of Genetic Factors for Precision Medicine of Antiplatelet Therapy in Diabetic Peripheral Artery Disease

Biomedicines ◽  
2022 ◽  
Vol 10 (1) ◽  
pp. 116
Author(s):  
Chi-Hsiao Yeh ◽  
Yi-Ju Chou ◽  
Tsung-Hsien Tsai ◽  
Paul Wei-Che Hsu ◽  
Chun-Hsien Li ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Precision Medicine ◽  
Antiplatelet Therapy ◽  
Peripheral Artery Disease ◽  
Cardiovascular Events ◽  
Genetic Factors ◽  
Genome Wide Association Study ◽  
Peripheral Artery ◽  
Increased Risk ◽  
Artery Disease

An increased risk of cardiovascular events was identified in patients with peripheral artery disease (PAD). Clopidogrel is one of the most widely used antiplatelet medications. However, there are heterogeneous outcomes when clopidogrel is used to prevent cardiovascular events in PAD patients. Here, we use an artificial intelligence (AI)-assisted methodology to identify genetic factors potentially involved in the clopidogrel-resistant mechanism, which is currently unclear. Several discoveries can be pinpointed. Firstly, a high proportion (>50%) of clopidogrel resistance was found among diabetic PAD patients in Taiwan. Interestingly, our result suggests that platelet function test-guided antiplatelet therapy appears to reduce the post-interventional occurrence of major adverse cerebrovascular and cardiac events in diabetic PAD patients. Secondly, AI-assisted genome-wide association study of a single-nucleotide polymorphism (SNP) database identified a SNP signature composed of 20 SNPs, which are mapped into 9 protein-coding genes (SLC37A2, IQSEC1, WASHC3, PSD3, BTBD7, GLIS3, PRDM11, LRBA1, and CNR1). Finally, analysis of the protein connectivity map revealed that LRBA, GLIS3, BTBD7, IQSEC1, and PSD3 appear to form a protein interaction network. Intriguingly, the genetic factors seem to pinpoint a pathway related to endocytosis and recycling of P2Y12 receptor, which is the drug target of clopidogrel. Our findings reveal that a combination of AI-assisted discovery of SNP signatures and clinical parameters has the potential to develop an ethnic-specific precision medicine for antiplatelet therapy in diabetic PAD patients.

scholarly journals Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures

2017 ◽  
Vol 26 (145) ◽  
pp. 170020 ◽  
Author(s):  
Vikas Pathak ◽  
J. Erin Allender ◽  
Mollie W. Grant
Keyword(s):  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Thromboembolic Events ◽  
Vein Thrombosis ◽  
Blood Tests ◽  
The Past ◽  
Increased Risk ◽  
Great Progress ◽  
Artery Disease ◽  
Deep Vein

There has been great progress in antithrombotic therapy over the past several years. Its use has increased with the advent of novel anticoagulants, as these medications do not require frequent blood tests for monitoring. Antithrombotic therapy is aimed at reducing the risk of thromboembolic events in patients with atrial fibrillation, coronary artery disease, deep vein thrombosis, valvular heart disease and pulmonary embolism. These patients are often critically ill and frequently undergo urgent interventions requiring discontinuation of anticoagulant or antiplatelet therapy which can increase the risk of thrombosis; however, continuing these agents can lead to increased risk of haemorrhage.The purpose of this article is to summarise the literature surrounding the safety of using antiplatelet and anticoagulant therapies in patients undergoing interventional pulmonary procedures.

scholarly journals Dual-Antiplatelet Therapy for More Than Six Months After Endovascular Revascularization in Patients With Lower-Extremity Artery Disease

2021 ◽  
Author(s):  
Jongkwon Seo ◽  
Byung Gyu Kim ◽  
Gwang Sil Kim ◽  
Moo-Nyun Jin ◽  
Hye Young Lee ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Lower Extremity ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Hazard Ratio ◽  
Intergroup Difference ◽  
Significant Intergroup Difference ◽  
Endovascular Revascularization ◽  
Artery Disease ◽  
Lower Extremity Artery Disease

Abstract Background: The duration of antiplatelet therapy after endovascular revascularization in patients with lower-extremity artery disease (LEAD) has not been well-established. This study aimed to investigate the optimal strategy for antiplatelet therapy after successful endovascular revascularization in patients with LEAD. Methods: From April 2009 to June 2019, 376 patients with LEAD underwent successful endovascular revascularization. After the procedure, the patients received mono-antiplatelet therapy (MAPT) or dual-antiplatelet therapy (DAPT) of various durations and were classified into 2 groups (MAPT or DAPT < 6 months vs. DAPT ≥ 6 months). The primary outcomes were major adverse cardiovascular events (MACE) and major adverse limb events (MALE). The safety outcome was moderate-to-severe bleeding according to the Global Use of Strategies to Open Occluded Arteries (GUSTO) criteria.Results: Over the 40-month follow-up period, MACE occurred less frequently in the DAPT ≥ 6 months group than the MAPT or DAPT < 6 months group (12.4% vs. 23.8%; hazard ratio: 0.62; 95% confidence interval: 0.40 to 0.97; p = 0.038) after inverse probability-weighted adjustment and propensity-score matching. The incidence of MALE showed no significant intergroup difference (17.1% vs. 13.1%; hazard ratio: 0.94; 95% confidence interval: 0.56 to 1.59; p = 0.822). The incidence of moderate-to-severe GUSTO bleeding also showed no significant intergroup difference (3.5% vs. 4.9%; hazard ratio: 0.59; 95% confidence interval: 0.21 to 1.63; p = 0.308). Conclusions: For patients with LEAD, DAPT for ≥6 months after endovascular revascularization was associated with a lower incidence of MACE without increasing the risk of bleeding events.

A systematic review of model-based economic evaluations of diagnostic and therapeutic strategies for lower extremity artery disease

2014 ◽  
Vol 111 (01) ◽  
pp. 19-28 ◽  
Author(s):  
Anil Vaidya ◽  
Manuela A. Joore ◽  
Arina J. ten Cate-Hoek ◽  
Marie-Claire Kleinegris ◽  
Hugo ten Cate ◽  
...  
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Methodological Quality ◽  
Economic Evaluations ◽  
Health Technologies ◽  
Model Based ◽  
Increased Risk ◽  
Artery Disease ◽  
Lower Extremity Artery Disease

SummaryLower extremity artery disease (LEAD) is a sign of wide spread atherosclerosis also affecting coronary, cerebral and renal arteries and is associated with increased risk of cardiovascular events. Many economic evaluations have been published for LEAD due to its clinical, social and economic importance. The aim of this systematic review was to assess modelling methods used in published economic evaluations in the field of LEAD. Our review appraised and compared the general characteristics, model structure and methodological quality of published models. Electronic databases MEDLINE and EMBASE were searched until February 2013 via OVID interface. Cochrane database of systematic reviews, Health Technology Assessment database hosted by National Institute for Health research and National Health Services Economic Evaluation Database (NHSEED) were also searched. The methodological quality of the included studies was assessed by using the Philips’ checklist. Sixteen model-based economic evaluations were identified and included. Eleven models compared therapeutic health technologies; three models compared diagnostic tests and two models compared a combination of diagnostic and therapeutic options for LEAD. Results of this systematic review revealed an acceptable to low methodological quality of the included studies. Methodological diversity and insufficient information posed a challenge for valid comparison of the included studies. In conclusion, there is a need for transparent, methodologically comparable and scientifically credible modelbased economic evaluations in the field of LEAD. Future modelling studies should include clinically and economically important cardiovascular outcomes to reflect the wider impact of LEAD on individual patients and on the society.

scholarly journals PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE AND ANTIPLATELET THERAPY. CLINICAL LECTURE

2017 ◽  
pp. 89-93
Author(s):  
L. O. Minushkina
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Primary Prevention ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Antiplatelet Agent ◽  
Term Therapy ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Artery Disease

Today, treatment with low doses of acetylsalicylic acid (ASA) (alone or in combination with other antiplatelet drugs) is the key element in the secondary prevention of coronary artery disease. Long-term therapy with low-dose ASA is recommended to patients with stable coronary artery disease, patients after acute coronary syndrome with or without ST segment elevation, and after revascularization. [1–3] The need for antithrombotic therapy in the primary prevention of cardiovascular events raises many questions. The currently available guidelines are contradictory – from complete denial of the need for antiplatelet therapy to designation of the specific groups of patients for whom ASA treatment is recommended. [4, 5] Findings of clinical trials underlie those contradictory opinions. ASA is the only antiplatelet agent the administration of which is debated for primary prevention. Administration of ASA in primary prevention usually results in a reduced risk of cardiovascular complications, but the positive effect is largely offset by an increased risk of bleeding, particularly gastrointestinal. Therefore, the challenge is in the selection of patients for whom the benefit from antithrombotic therapy could outweigh the risks associated with bleeding. Risk scores are commonly used to assess the risk of complications.

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