Key result
Prolonged DAPT or aspirin plus anticoagulation increases bleeding in chronic PAD and CAD.
Why the study?
Patients with both PAD and CAD have high residual risk for MACE and MALE, but the optimal antithrombotic intensity and balance with bleeding risk remain debated.
Does higher-intensity antithrombotic therapy reduce MACE and MALE compared to lower-intensity therapy in patients with chronic PAD and CAD?
Does higher-intensity antithrombotic therapy reduce MACE and MALE compared to lower-intensity therapy in patients with chronic PAD and CAD?
This review highlights the need for tailored, higher-intensity antithrombotic strategies in patients with concomitant PAD and CAD to balance cardiovascular and limb benefits against increased bleeding risks.
May warrant caution with intensified antithrombotic regimens in chronic PAD/CAD; leaves open net benefit on ischemic events.
Despite evidence-based therapies, patients presenting with atherosclerosis involving more than one vascular bed, such as those with peripheral artery disease (PAD) and concomitant coronary artery disease (CAD), constitute a particularly vulnerable group characterized by enhanced residual long-term risk for major adverse cardiac events (MACE), as well as major adverse limb events (MALE). The latter are progressively emerging as a difficult outcome to target, being correlated with increased mortality. Antithrombotic therapy is the mainstay of secondary prevention in both patients with PAD or CAD; however, the optimal intensity of such therapy is still a topic of debate, particularly in the post-acute and long-term setting. Recent well-powered randomized clinical trials (RCTs) have provided data in favor of a more intense antithrombotic therapy, such as prolonged dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor or a therapy with aspirin combined with an anticoagulant drug. Both approaches increase bleeding and selection of patients is a key issue. The aim of this review is, therefore, to discuss and summarize the most up-to-date available evidence for different strategies of anti-thrombotic therapies in patients with chronic PAD and CAD, particularly focusing on studies enrolling patients with both types of atherosclerotic disease and comparing a higher- versus a lower-intensity antithrombotic strategy. The final objective is to identify the optimal tailored approach in this setting, to achieve the greatest cardiovascular benefit and improve precision medicine.
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Magnani et al. (2023) conducted a review in Peripheral artery disease and chronic coronary artery disease. Dual antiplatelet therapy or antiplatelet plus anticoagulant therapy vs. Lower-intensity antithrombotic strategy was evaluated. Prolonged dual antiplatelet therapy or aspirin combined with an anticoagulant drug increases bleeding, highlighting the need for careful patient selection in patients with chronic PAD and CAD.
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