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Canadian Journal of Cardiology

Antithrombotic Therapy in Peripheral Artery Disease: Risk Stratification and Clinical Decision Making

Published:February 26, 2022DOI:https://doi.org/10.1016/j.cjca.2022.02.018

      Abstract

      Patients with peripheral artery disease (PAD) are an underrecognised group with significant thrombotic risk. This risk is modifiable with the use of aggressive secondary preventative efforts, including optimisation of antithrombotic therapy. Appropriate antithrombotic selection for patients with PAD requires appropriate assessment of thrombotic and bleeding risk. Recent Canadian guidelines have recommended dual pathway therapy initiation for stable PAD and post-revascularisation patients. However, there is ongoing discussion about how to identify PAD patients who stand to benefit most from these therapies while trying to minimise harm from bleeding. Clinical equipoise also persists around questions such as the utility of dual antiplatelet therapy in conjunction with rivaroxaban after high-risk endovascular interventions and the optimal therapy for patients experiencing acute limb ischemia. In patients with chronic PAD and high-risk comorbidities or limb features, or in patients after revascularisation, dual pathway therapy with low-dose rivaroxaban and aspirin has emerged as the only regimen to reduce major adverse cardiovascular and limb events while maintaining an acceptable bleeding profile. After endovascular revascularisation, limited-duration (< 30 days) clopidogrel may be added to rivaroxaban and aspirin in selected high-risk patients at the provider’s discretion. After acute limb ischemia, the risk of another vascular event is exceptionally high, but there is no high-quality evidence to guide decision making for intensified antithrombotic therapy. Randomised investigations addressing this question are urgently needed to better serve this high-risk and vulnerable population.

      Résumé

      Les patients atteints d’une maladie artérielle périphérique (MAP) font partie d’un groupe méconnu exposé à un risque thrombotique important. Ce risque est modifiable par des mesures énergiques en prévention secondaire, notamment l’optimisation du traitement antithrombotique. Le choix du traitement antithrombotique convenant aux patients atteints d’une MAP nécessite la pondération adéquate des risques thrombotique et hémorragique. D’après les lignes directrices canadiennes récentes, il est recommandé d’instaurer un traitement inhibant deux voies différentes chez les patients atteints d’une MAP stable et chez ceux venant de subir une revascularisation. Toutefois, la question de savoir comment reconnaître les patients atteints d’une MAP susceptibles de bénéficier le plus de ces traitements en essayant de limiter au maximum les risques d’hémorragie n’a pas encore été tranchée. Une question d’équilibre clinique persiste également quant à l’utilité d’une bithérapie antiplaquettaire associée au rivaroxaban après des interventions endovasculaires à risque élevé, ou encore au traitement optimal pour les patients atteints d’une ischémie aiguë à un membre. Chez les patients atteints d’une MAP chronique et d’affections concomitantes à risque élevé ou encore de manifestations reflétant l’atteinte d’un membre, ou chez ceux venant de subir une revascularisation, le traitement inhibant deux voies différentes, dont le rivaroxaban et l’acide acétylsalicylique à faible dose, est devenu le seul schéma thérapeutique permettant de réduire les taux d’événements cardiovasculaires indésirables majeurs et d’événements indésirables majeurs touchant un membre tout en maintenant un bilan hémorragique acceptable. Après une revascularisation endovasculaire, un traitement à durée limitée (moins de 30 jours) par le clopidogrel peut être ajouté au rivaroxaban et à l’acide acétylsalicylique chez certains patients exposés à un risque élevé, à la discrétion du prestataire de soins. Après l’ischémie aiguë d’un membre, le risque d’un autre événement vasculaire est particulièrement élevé, mais il n’existe aucune donnée probante de bonne qualité permettant d’orienter les prises de décisions concernant l’intensification du traitement antithrombotique. Il est donc indispensable de mener des études à répartition aléatoire visant à répondre à cette question pertinente pour cette population vulnérable exposée à un risque élevé.
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