Optimal strategy for antiplatelet therapy after endovascular revascularization for lower extremity peripheral artery disease
Selected in JACC: Cardiovascular Interventions by M. Alasnag
The aim of this study was to examine the optimal strategy for antiplatelet therapy for patients with lower extremity peripheral artery disease (PAD) following endovascular repair
References
Authors
Cho S, Lee YJ, Ko YG, Kang TS, Lim SH, Hong SJ, Ahn CM, Kim JS, Kim BK, Choi D, Hong MK, Jang Y.
Reference
JACC Cardiovasc Interv. 2019 Dec 9;12(23):2359-2370
Published
December 2019
Link
Read the abstractReviewer
My Comment
Why this study – the rationale/objective?
To date, both the 2017 European Society of Cardiology and the 2016 American Heart Association/American College of Cardiology Guidelines recommend long term single antiplatelet therapy for patients with lower extremity peripheral artery disease (PAD) following endovascular repair. Dual antiplatelet therapy (DAPT) is currently recommended for only one month. However, there is limited evidence behind the recommendation for a short DAPT course. The aim of this study was to examine the optimal strategy for antiplatelet therapy in this population.
How was it executed – the methodology?
This is a retrospective analysis of two registries in South Korea between March 2008 and February 2013. A total of 869 patients with claudication or critical limb ischemia who underwent endovascular repair were identified. Those on anticoagulation or with nonatherosclerotic causes of disease were excluded. The remaining 693 patients were classified into 2 groups (DAPT <6 months or single vs. DAPT> 6 months). All patients received a maintenance dose of aspirin (100 mg) and clopidogrel (75 mg) for at least 5 days before the procedure or a loading dose of aspirin (300 mg) and clopidogrel (300 mg) 1 day before the procedure. The procedural data included target lesion location, TASC (TransAtlantic InterSociety Consensus for the Management of Peripheral Arterial Disease) classification (TASC II for aortoiliac and femoropopliteal levels and TASC I for infrapopliteal level), multilevel disease, intervention type (balloon angioplasty or stent insertion), and pre- and post-intervention ankle-brachiaI Index. Patients were seen 1 month after the procedure followed by 3-month intervals.
The primary outcomes were major adverse cardiovascular events and major adverse limb events. The safety outcome was major bleeding.
What is the main result?
The median duration of the study was 39.8 months. 404 patients were treated with DAPT or single anti-platelet therapy <6 months and 289 patients were treated >6 months. Those on a longer duration were more likely to be male , smokers, dyslipidemic, and have coronary artery disease. Adjunctive medical therapy including statins and angiotensin converting enzyme inhibitors were also more likely in those on a longer duration of DAPT.
Major adverse cardiovascular events occurred less frequently in the DAPT > 6-month group compared to the single or DAPT <6-month group (17.3% vs. 31.3%; p < 0.001). Major adverse limb events also occurred less frequently in the DAPT> 6-month group compared to the single or DAPT <6-month group (21.5% vs. 43.7%; p < 0.001). Specifically, all-cause death, reinterventions for target lesions, and major amputations were all lower in those receiving DAPT > 6 months. In terms of safety, the bleeding events were infrequent with DAPT > 6 months. These results persisted after propensity score matching.
Critical reading and relevance for clinical practice
This observational data highlights the wide variability in antiplatelet regimens in practice and emphasizes a need to standardize care. The study of course only examined aspirin and clopidogrel. These results cannot be used to make assertions for other more potent P2Y12 inhibitors or direct oral anticoagulants which have been studied in trials such as the COMPASS trial (Rivaroxaban in stable peripheral vascular disease) or combinations (triple therapy).
A primary limitation of the study is that it is nonrandomized observational data from one region that may not be widely applicable to other populations. Novel technologies used in peripheral interventions such as laser or orbital atherectomy or drug-eluting balloons and stents were not included which is another limitation of this study. Finally, the study was not powered to detect differences in major bleeding between the groups impacting safety conclusions.
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