Antithrombotic Strategies for Patients with Peripheral Artery Disease: JACC Scientific Statement (JACC September 2024-1)-Article: Antithrombotic Strategies for Patients with Peripheral Artery Disease: JACC Scientific Statement

Article: Antithrombotic Strategies for Patients with Peripheral Artery Disease: JACC Scientific Statement

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The review discusses the optimal antithrombotic strategies for patients with peripheral artery disease (PAD), highlighting the high cardiovascular and limb risk these patients face. The assessment and treatment should be personalized, factoring in the benefits and risks, particularly due to the heterogeneous responses to antithrombotic therapies.<br /><br />### Key Findings:<br /><br />1. **Antithrombotic Therapies**:<br />   - Antiplatelets and anticoagulants are crucial for treating PAD.<br />   - Recent trials reveal differing responses in PAD patients compared to those with coronary artery disease.<br />   - The risk of bleeding necessitates a patient-centered approach to therapy selection.<br /><br />2. **PAD-Specific Risks**:<br />   - PAD is linked to heightened risk equivalent to prior myocardial infarction or stroke.<br />   - Major adverse limb events (MALE) like acute limb ischemia and amputation are common in PAD.<br />   - PAD is often underdiagnosed, leading to untreated progression and severe outcomes including critical limb-threatening ischemia (CLTI), acute limb ischemia, myocardial infarction, or death.<br /><br />3. **Treatment Guidelines and Studies**:<br />   - **Aspirin and Clopidogrel**: Common for MACE reduction but show no benefit for reducing MALE.<br />   - **Dual Pathway Inhibition (DPI)**: Combining low-dose rivaroxaban (2.5 mg twice daily) with aspirin has shown efficacy in reducing both MACE and MALE, with an acceptable bleeding risk profile.<br />   - **Vorapaxar**: Reduces both MACE and MALE but increases bleeding risk.<br />   - **Clinical Trials**: Highlight the complexity and heterogeneity in response, stressing the need for personalized treatment approaches.<br /><br />4. **Patient Risk Stratification**:<br />   - Evaluating the risk for both MACE and MALE, incorporating comorbidities (e.g., diabetes, chronic kidney disease) is crucial.<br />   - High-risk patients may benefit more from intense antithrombotic therapy whereas those at higher bleeding risk might need more conservative approaches.<br /><br />5. **Challenges and Future Directions**:<br />   - Ongoing and future trials aim to differentiate outcomes across PAD populations.<br />   - Implementation science is crucial to improve diagnostic rates and adherence to evidence-based therapies.<br />   - Novel therapies like Factor XI/XIa inhibitors hold promise for safer antithrombotic strategies in high-risk PAD patients.<br /><br />In summary, the review emphasizes the importance of personalized and comprehensive management of PAD, integrating recent trial evidence and guideline recommendations to optimize patient outcomes while minimizing adverse effects. Future research and better implementation practices are needed to address the significant care gaps in this high-risk population.

Keywords

Peripheral Artery Disease

Antithrombotic Therapies

Personalized Treatment

Cardiovascular Risk

Limb Risk

Major Adverse Limb Events

Dual Pathway Inhibition

Patient Risk Stratification

Clinical Trials

Future Directions