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

Franzone, Anna; Piccolo, Raffaele; Gargiulo, Giuseppe; Ariotti, Sara; Marino, Marcello; Santucci, Andrea; Baldo, Andrea; Moschovitis, Aris; Windecker, Stephan; Valgimigli, Marco

doi:10.1001/jamacardio.2016.2811

Cited by 73 publications

(47 citation statements)

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“…Those patients with multiple symptomatic territories (eg, PAD and prior MI or prior stroke), called polyvascular disease, are at clearly heightened risk and appear to derive robust reductions in MACE risk from more intensive antithrombotic therapy. 3,23,24 For patients with symptomatic PAD and no prior MI or stroke, there were fewer proven medical therapies. 4,5,15,25 The current study builds on observations from the Heart Protection Study and observational analyses to demonstrate that intensive lipid lowering is beneficial in this population and has no offsetting side effects such as bleeding with antithrombotic therapy.…”

Section: Discussionmentioning

confidence: 99%

Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease

et al. 2018

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BACKGROUND:The PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor evolocumab reduced low-density lipoprotein cholesterol and cardiovascular events in the FOURIER trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk). We investigated the efficacy and safety of evolocumab in patients with peripheral artery disease (PAD) as well as the effect on major adverse limb events. METHODS:FOURIER was a randomized trial of evolocumab versus placebo in 27 564 patients with atherosclerotic disease on statin therapy followed for a median of 2.2 years. Patients were identified as having PAD at baseline if they had intermittent claudication and an ankle brachial index of <0.85, or if they had a prior peripheral vascular procedure. The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, hospital admission for unstable angina, or coronary revascularization. The key secondary end point was a composite of cardiovascular death, myocardial infarction, or stroke. An additional outcome of interest was major adverse limb events defined as acute limb ischemia, major amputation, or urgent peripheral revascularization for ischemia. RESULTS:Three thousand six hundred forty-two patients (13.2%) had PAD (1505 with no prior myocardial infarction or stroke). Evolocumab significantly reduced the primary end point consistently in patients with PAD (hazard ratio [HR] 0.79; 95% confidence interval [CI], 0.66-0.94; P=0.0098) and without PAD (HR 0.86; 95% CI, 0.80-0.93; P=0.0003; P interaction =0.40). For the key secondary end point, the HRs were 0.73 (0.59-0.91; P=0.0040) for those with PAD and 0.81 (0.73-0.90; P<0.0001) for those without PAD (P interaction =0.41). Because of their higher risk, patients with PAD had larger absolute risk reductions for the primary end point (3.5% with PAD, 1.6% without PAD) and the key secondary end point (3.5% with PAD, 1.4% without PAD). Evolocumab reduced the risk of major adverse limb events in all patients (HR, 0.58; 95% CI, P=0.0093) with consistent effects in those with and without known PAD. There was a consistent relationship between lower achieved low-density lipoprotein cholesterol and lower risk of limb events (P=0.026 for the beta coefficient) that extended down to <10 mg/dL. CONCLUSIONS:Patients with PAD are at high risk of cardiovascular events, and PCSK9 inhibition with evolocumab significantly reduced that risk with large absolute risk reductions. Moreover, lowering of low-density lipoprotein cholesterol with evolocumab reduced the risk of major adverse limb events.

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Section: Discussionmentioning

confidence: 99%

Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease

et al. 2018

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“…Wśród wszystkich uczestników badania PRODIGY u 246 (12,5%) chorych stwierdzono objawową LEAD. Rozpoznanie LEAD wiązało się z wyższym ryzykiem zgonu i zdarzeń niedokrwiennych (HR 2,80; 95% CI 2,05-3,83; p < 0,001) [246]. Wydłużone stosowanie DAPT vs. krótki okres DAPT powodował obniżenie ryzyka wystąpienia pierwszorzędowego punktu końcowego w ocenie skuteczności u pacjentów z LEAD (16,1% vs. 27,3%; HR 0,54; 95% CI 0,31-0,95; p = 0,03), lecz nie u osób bez LEAD (9,3% vs. 7,4%; HR 1,28; 95% CI 0,92-1,77; p = 0,14), z dodatnim testem dla interakcji (p = 0,01).…”

Section: Miażdżyca Tętnic Kończyn Dolnychunclassified

2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS

Valgimigli

Bueno²,

Byrne³

et al. 2017

Kardiol Pol

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224

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“…The co-occurrence of LEAD and coronary artery disease is related to worse prognosis, and the presence of LEAD in patients might be an argument for a prolonged DAPT. In PRODIGY trial, which compared different durations of DAPT (clopidogrel and ASA) after coronary artery stenting, DAPT prolonged to 24 months reduced the risk of MACE in the subgroup of patients with co-occurring LEAD, as compared to a 6-month DAPT; however, for the entire group, no evidence of superiority of prolonged DAPT was found [87,88]. PEGASUS-TIMI 54 trial assessed prolonged use of ticagrelor in the dose of 90 mg or 60 mg bid, combined with a low dose of ASA, in stable patients who had suffered from a myocardial infarction (1-3 years prior) [89].…”

Section: Dual Antiplatelet Therapy In Patients With Lower Extremity Amentioning

confidence: 99%

The position of Polish experts on conservative management in patients with artery diseases of lower limbs

Krasiński¹,

Gaciong

Szymański

et al. 2019

Acta Angiologica

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Peripheral artery disease (PAD) is a common disease, though not very well known and often diagnosed on a very late stage, causing not only typical complications such as intermittent claudication, critical limb ischemia or amputations, but also to cardiovascular mortality. The risk of cardiovascular death can be even 11 times higher in patients with symptomatic PAD than in healthy patients. The risk of heart attack, stroke or cardiovascular death is even higher, reaching almost 4% within one year, nearly equal to the risk for patients with coronary artery disease (CAD). In those patients, the 5-year mortality risk is estimated at 10-15%, with cardiovascular disorders being the most likely cause of death. In patients with critical limb ischemia, the risk of cardiovascular death within one year can be as high as 25% and the risk of amputation-30%. It is estimated that the global population of patients with PAD is over 120 million. The incidence of the diseases is 3-10%, but in patients aged 70 and more, the incidence increases to 14-29%. In Poland, around 4,000 people are hospitalized every year for PAD of lower limbs. The number of PAD-related amputations is over 9,000 per year. Although the methods of PAD diagnosis (e.g. ABI) are often easy and non-invasive, they are scarcely used in clinical practice. Also, optimal conservative management in the form of quitting smoking, modifying the cardiovascular risk factors and supervised exercise is often overlooked. PAD is a major issue not only for vascular surgery, but also for many other medical specializations, including angiology, general medicine, cardiology, or diabetology. As a result of long waiting times for the next visit and lack of access to patient programmes and reimbursed drugs, patients with PAD often report to the doctor when their condition is very serious. Despite the 2017 ESC guidelines on the diagnosis and treatment of peripheral artery disease, prepared together with ESVS, not all healthcare professionals have access to the latest knowledge on PAD diagnosis and treatment. Unfortunately, though published recently, the ESC's guidelines do not include some of the recent studies, among them the possibly breakthrough COMPASS trial which has the potential to change the paradigm of management of patients with PAD. We must bear in mind that the population with PAD is a difficult patient group who need new treatment methods and optimization of the existing ones in order to visibly improve diagnosis, treatment and prognosis.

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

Abstract: clinicaltrials.gov Identifier: NCT00611286.

Cited by 73 publications

References 30 publications

Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease

Low-Density Lipoprotein Cholesterol Lowering With Evolocumab and Outcomes in Patients With Peripheral Artery Disease

2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS

The position of Polish experts on conservative management in patients with artery diseases of lower limbs

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