Key result
DOACs fail to reduce MACE vs antiplatelets in PAD, lowering limb ischemia but increasing major bleeding.
Why the study?
The efficacy and safety of direct oral anticoagulants in patients with peripheral arterial disease are not completely understood.
Do DOACs reduce cardiovascular and limb events in patients with peripheral arterial disease?
Meta-Analysis
Do DOACs reduce cardiovascular and limb events in patients with peripheral arterial disease?
In patients with peripheral arterial disease, DOACs reduce acute limb ischemia and target lesion revascularization but increase major bleeding compared to antiplatelet monotherapy, with no difference in MACE or mortality.
DOACs should not replace antiplatelet monotherapy for MACE reduction in PAD due to bleeding risk; challenges broad antithrombotic intensification while extending limb-event data.
Background The efficacy and safety of direct oral anticoagulants (DOACs) in patients with peripheral arterial disease are not completely understood. Therefore, we conducted a meta-analysis to explore the effects of DOACs in this population. Methods We systematically searched the PubMed, Cochrane Library, and Web of Science till April 2020 for relevant randomized controlled trials and observational studies, with no linguistic restrictions. The efficacy outcomes were cardiovascular death, stroke, myocardial infraction, major adverse cardiovascular events (MACE), acute limb ischemia, amputation, and target lesion revascularization. The safety outcome was major bleeding events. Random effects risk ratios with 95% confidence intervals were calculated. Results A total four randomized controlled trials were included in this meta-analysis. Among peripheral arterial disease patients, DOACs did not reduce the risk of cardiovascular death (RR = 1.02 95%CI 0.75–1.37, P = 0.92), stroke (RR = 0.73 95%CI 0.46–1.14, P = 0.16), myocardial infraction (RR = 0.85 95%CI 0.70–1.03, P = 0.10), MACE (RR = 0.73 95%CI 0.46–1.14, P = 0.16), or amputation (RR = 0.73 95%CI 0.46–1.14, P = 0.16) compared with control. However, DOACs were associated with reduction in acute limb ischemia (RR = 0.67 95%CI 0.55–0.80, P < 0.01) and target lesion revascularization (RR = 0.89 95%CI 0.81–0.99, P = 0.02) at the expense of major bleeding events (RR = 1.43 95%CI 1.16–1.77, P < 0.01) compared with control. Conclusions Based on current evidence, no significant difference in cardiovascular death, stroke, myocardial infraction, MACE, and amputation was found when DOACs were compared to antiplatelet monotherapy. The benefits of preventing target lesion revascularization and acute limb ischemia were balanced by amplified risk of major bleeding. Larger randomized controlled trials are needed to figure out the uncertainty around efficacy and safety of medications for peripheral arterial disease.
No takes yet. Share an insight, caveat, or question.
Zhang et al. (2021) conducted a meta-analysis in peripheral arterial disease. direct oral anticoagulants (DOACs) vs. antiplatelet monotherapy was evaluated on major adverse cardiovascular events (MACE) (RR 0.73, 95% CI 0.46-1.14, p=0.16). DOACs compared to antiplatelet monotherapy in peripheral arterial disease did not significantly reduce MACE (RR 0.73; 95% CI 0.46-1.14) but reduced acute limb ischemia at the cost of major bleeding.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: