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

Armstrong, Ehrin J.; Anderson, David R.; Yeo, Khung Keong; Singh, Gagan D.; Bang, Heejung; Amsterdam, Ezra A.; Freischlag, Julie A.; Laird, John R.

doi:10.1016/j.jvs.2015.01.051

Cited by 62 publications

(56 citation statements)

References 45 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We chose to study only Aspirin as our mono-antiplatelet group as it makes this study more readily comparable to CHARISMA and to Armstrong et al, and is the most common antiplatelet agent used in patients with PAD. [20, 21]…”

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

Dual antiplatelet therapy is associated with prolonged survival after lower extremity revascularization

Soden

Zettervall

Ultee

et al. 2016

Journal of Vascular Surgery

View full text Add to dashboard Cite

Introduction Dual antiplatelet therapy (DAPT) after coronary stenting prolongs survival by preventing both in-stent thrombosis and other cardiovascular atherothrombotic events. Patients with peripheral artery disease (PAD) typically have a heavy burden of unrevascularized coronary artery disease and also stand to benefit from increased atherothrombotic protection with DAPT. The potential benefit of DAPT compared to aspirin alone in patients with PAD is not well described. Methods We identified all patients undergoing an initial elective lower extremity revascularization (bypass or endovascular) from 2003 to 2016 in the Vascular Quality Initiative (VQI) registry discharged on aspirin or aspirin plus a thenopyradine anti-platelet agent (dual anti-platelet therapy (DAPT)). We first estimated models predicting the likelihood of receiving DAPT and then used inverse probability weighting to account for baseline differences in the likelihood to receive DAPT and compared late survival. For sensitivity analysis we also performed Cox proportion hazard modeling on the unweighted cohorts and generated adjusted survival curves. Results We identified 57,041 patients undergoing lower extremity revascularization (28% bypass). Of 15,985 bypasses (69% for critical limb ischemia (CLI)) 38% were discharged on DAPT. Of 41,056 endovascular interventions (39% for CLI) 69% were discharged on DAPT. Analyses using inverse probability weighting demonstrated small survival benefits to DAPT at one-year for bypass (93% vs. 92%, P = .001) and endovascular interventions (93% vs. 92%, P = .005) that was sustained through five-years of follow-up (bypass: 80% vs. 78%, P = .004; Endovascular: 76% vs. 73%, P = .002). When stratified by severity of PAD, DAPT had a survival benefit for patients with CLI undergoing bypass (five-year: 70% vs. 66%, P = .04) and endovascular intervention (five-year: 71% vs. 67%, P = .01) but not for patients with claudication (bypass: 89% vs. 88%, P = .36; endovascular: 87% vs. 85%, P = .46). The protective effect of DAPT was similar when using Cox Proportional hazard models after bypass (HR 0.81, 95% CI 0.72 – 0.90) and endovascular intervention (HR 0.89, 0.83 – 0.95). Conclusion Dual antiplatelet therapy at time of discharge was associated with prolonged survival for patients with CLI undergoing lower extremity revascularization but not for those with claudication. Further research is needed to quantify the risks associated with DAPT and to identify subgroups at increased risk of thrombotic and bleeding complications in order to guide medical management of patients with PAD.

show abstract

Section: Methodsmentioning

confidence: 99%

“…An early single-center observational study in a PAD population showed a reduction in MACE and mortality associated with DAPT, and subgroup analysis from the CHARISMA trial, showed a similar reduction in MI associated with DAPT, suggesting this might be true. [20, 21]…”

Section: Introductionmentioning

confidence: 99%

Dual antiplatelet therapy is associated with prolonged survival after lower extremity revascularization

Soden

Zettervall

Ultee

et al. 2016

Journal of Vascular Surgery

View full text Add to dashboard Cite

show abstract

“…After a median follow-up period of over 2 years, the primary composite endpoint of MI, stroke, or death from cardiovascular causes did not differ significantly among treatment groups in the overall cohort (6.8 % in the DAPT group vs 7.3 % in the aspirin monotherapy group; HR 0.93; 95 % CI 0.83-1.05; p = 0.22) or in the subgroup of 3096 patients with PAD (7.6 % in the DAPT group vs 8.9 % in the aspirin monotherapy group; HR 0.85; 95 % CI 0.66-1.08; p = 0.18) [44]. A recent observational cohort analysis of 629 patients with symptomatic PAD undergoing diagnostic or interventional lower extremity angiography demonstrated lower rates of MACE (HR 0.65; 95 % CI 0.44-0.96) and overall mortality (HR 0.55; 95 % CI 0.35-0.89) in patients treated with DAPT compared to aspirin alone, suggesting that longer-term DAPT may improve outcomes in patients with PAD undergoing endovascular interventions [45].…”

Section: Antithrombotic Therapymentioning

confidence: 99%

“…Data regarding the optimal duration of antiplatelet therapy following endovascular intervention is limited. Most patients are treated with indefinite aspirin therapy and 1 to 3 months of clopidogrel, a practice extrapolated from data for PCI, though observational data suggests that longerterm DAPT may improve outcomes in patients with PAD undergoing endovascular interventions [45]. Finally, vorapaxar has been shown to reduce acute limb ischemia and need for revascularization in patients with PAD, including those with recent surgical and endovascular revascularization, with an attendant risk of bleeding [46•, 82].…”

Section: Antithrombotic Therapy Following Revascularizationmentioning

confidence: 99%

Medical Therapy in Peripheral Artery Disease and Critical Limb Ischemia

Foley

Waldo

Armstrong

2016

Curr Treat Options Cardio Med

Self Cite

View full text Add to dashboard Cite

Peripheral artery disease (PAD) comprises atherosclerosis of the aorta and lower extremities. Many patients with PAD are asymptomatic, while others present with intermittent claudication (IC) or critical limb ischemia (CLI). Defined as rest pain or tissue loss that persists for >2 weeks, CLI represents the most severe clinical manifestation of PAD and is associated with an increased risk of limb loss and death. Patients with PAD, including those with CLI, are underdiagnosed and undertreated. In addition to smoking cessation, medical therapy with an antiplatelet agent and statin is recommended for all patients with PAD. Regular exercise has been shown to improve walking distance and quality of life in patients with symptomatic PAD and should be incorporated into each patient's treatment plan. In patients who have CLI and in those with persistent lifestyle-limiting claudication despite optimal medical therapy and an exercise program, revascularization is indicated for limb salvage and symptom relief, respectively. Consensus guidelines currently support an endovascular first approach to revascularization in the majority of cases. Surgical procedures provide an alternative to endovascular therapy in select cases.

show abstract

“…The relatively lower rate of statin and P2Y12 inhibitor utilization is a crucial shortcoming in the optimization of medical therapy in these patients given the known protective role for limb. 15,16 Third, the authors meticulously examined the potential interaction between frailty and 3 clinical factors: age ≤75 or >75 years old, endovascular versus surgical revascularization, and renal function status. Additional analyses on the other baseline characteristics that significantly differed based on the frailty score (ie, body mass index, dyslipidemia, diabetes mellitus, smoking status, Rutherford classification, and tissue loss) would have been instructive.…”

mentioning

confidence: 99%

Frailty for Critical Limb Ischemia

Shishehbor

2018

Circ: Cardiovascular Interventions

View full text Add to dashboard Cite

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

Abstract: DAPT may be associated with reduced rates of MACEs and death among patients with symptomatic peripheral arterial disease.

Cited by 62 publications

References 45 publications

Dual antiplatelet therapy is associated with prolonged survival after lower extremity revascularization

Dual antiplatelet therapy is associated with prolonged survival after lower extremity revascularization

Medical Therapy in Peripheral Artery Disease and Critical Limb Ischemia

Frailty for Critical Limb Ischemia

Contact Info

Product

Resources

About