AntithromboticTherapyinPeripheral

ArteryDisease

AntithromboticTherapyand
PreventionofThrombosis,9thed:
AmericanCollegeofChestPhysicians
EvidenceBasedClinicalPractice
Guidelines

Copyright:AmericanCollegeofChestPhysicians2012

Introduction(I)
Theleadingcausesofmorbidityandmortalityin
patientswithPeripheralArterialDisease(PAD)are
myocardialinfarctionandstroke.
Theprimarygoalofantithrombotictherapyisthe
preventionofmajorvasculareventsand,ultimately,
mortality.

Introduction
Thisguidelinefocusesonantithromboticdrugtherapies
for:
Primaryandsecondarypreventionofcardiovascular
disease
Reliefoflowerextremitysymptomsandcritical
ischemia
Otherpatientsandtheirspecificoutcomesareincluded:
Peripheralarterialrevascularization
Carotidstenosis(symptomaticandasymptomatic)
Carotidendarterectomy

PrimaryPreventionofCardiovascularEventsinPatientsWith
AsymptomaticPAD
Forpersonswithasymptomaticperipheralarterialdisease
(PAD),wesuggestaspirin75to100mgdailyovernoaspirin
therapy(Grade2B).
Remarks:Aspirinslightlyreducestotalmortalityregardlessofcardiovascular
riskprofileiftakenover10years.Inpeopleatmoderatetohighriskof
cardiovascularevents,thereductioninmyocardialinfarction(MI)isclosely
balancedwithanincreaseinmajorbleeds.Whatevertheirriskstatus,people
whoareaversetotakingmedicationoveraprolongedtimeperiodforverysmall
benefitswillbedisinclinedtouseaspirinforprimaryprophylaxis.Individuals
whovaluepreventinganMIsubstantiallyhigherthanavoidingaGIbleed,if
theyareinthemoderateorhighcardiovascularriskgroup,willbemorelikelyto
chooseaspirin.

SecondaryPreventionofCardiovascularEventsin
PatientsWithSymptomaticPAD

ForsecondarypreventionpatientswithsymptomaticPAD,we
recommendoneofthetwofollowingantithromboticregimens
tobecontinuedlongtermovernoantithrombotictreatment:
aspirin75to100mgdailyorclopidogrel75mgdaily(allGrade
1A).Wesuggestnottousedualantiplatelettherapywith
aspirinplusclopidogrel(Grade2B).Werecommendnottouse
anantiplateletagentwithmoderateintensitywarfarin(Grade
1B).

AntithromboticTherapyfortheManagementofPatientsWithClaudication

Forpatientswithintermittentclaudicationrefractoryto
exercisetherapy(andsmokingcessation),wesuggesttheuseof
cilostazolinadditiontopreviouslyrecommended
Antithrombotictherapies(aspirin75100mgdailyor
clopidogrel75mgdaily)(Grade2C);wesuggestagainsttheuse
ofpentoxifylline,heparinoids,orprostanoids(Grade2C).

PatientsWithCriticalLimbIschemia
ForpatientswithsymptomaticPADandcriticalleg
ischemia/restpainwhoarenotcandidatesforvascular
intervention,wesuggesttheuseofprostanoidsinadditionto
previously
recommendedantithrombotictherapies(aspirin75100mg
dailyorclopidogrel75mgdaily)(Grade2C).
Valuesandpreferences:Patientswhodonotvalueuncertainrelief
ofrestpainandulcerhealinggreaterthanavoidanceofahigh
likelihoodofdrugrelatedsideeffectswillbedisinclinedtotake
prostanoids.

AcuteLimbIschemia
Inpatientswithacutelimbischemiaduetoarterialembolior
thrombosis,wesuggestimmediatesystemicanticoagulation
withunfractionatedheparinovernoanticoagulation(Grade
2C);wesuggestreperfusiontherapy(surgeryorintraarterial
thrombolysis)overnoreperfusiontherapy(Grade2C);we
recommendsurgeryoverintraarterialthrombolysis(Grade
1B).Inpatientsundergoingintraarterialthrombolysis,we
suggestrecombinanttissuetypeplasminogenactivator(rtPA)
orurokinaseoverstreptokinase(Grade2C).

EndovascularRevascularizationinPatientsWithSymptomaticPAD

Forpatientsundergoingperipheralarterypercutaneous
transluminalangioplasty(PTA)withorwithoutstenting,we
recommendlongtermaspirin(75100mg/day)orclopidogrel
(75mg/day)(Grade1A).Forpatientsundergoingperipheral
arteryPTAwithstenting,wesuggestsingleratherthandual
antiplatelettherapy(Grade2C).
Valuesandpreferences:PatientsundergoingperipheralPTAwith
stentingwhoplaceahighvalueonanuncertainreductioninthe
riskoflimblossandarelativelylowvalueonavoidingadefinite
increasedriskofbleedingaremorelikelytochoosetousedual
antiplatelettherapy.

AntithromboticTherapyFollowingPeripheralArteryBypassGraftSurgery

Werecommendoneofthefollowingantithromboticregimens
tobecontinuedlongtermfollowingperipheralarterybypass
graftsurgeryovernoantithrombotictreatment:aspirin75to
100mgdailyorclopidogrel75mgdaily(allGrade1A).We
recommendsingleantiplatelettherapyoverantiplatelet
therapyandwarfarin(Grade1B).
Inpatientsundergoingbelowkneebypassgraftsurgerywith
prostheticgrafts,wesuggestclopidogrel75mg/dplusaspirin
(75100mg/d)overaspirinalonefor1year(Grade2C).
Forallotherpatients,wesuggestsingleoverdualantiplatelet
therapy(Grade2B).

PatientsWithCarotidArteryStenosis
Forpersonswithasymptomaticcarotidstenosis,wesuggest
aspirin75to100mgdailyovernoaspirintherapy(Grade2B).
Remarks:Aspirinslightlyreducestotalmortalityregardlessof
cardiovascularriskprofileiftakenover10years.Inpeopleat
moderatetohighriskofcardiovascularevents,thereductioninMI
iscloselybalancedwithanincreaseinmajorbleeds.Whatever
theirriskstatus,peoplewhoareaversetotakingmedicationovera
prolongedtimeperiodforverysmallbenefitswillbedisinclinedto
useaspirinforprimaryprophylaxis.

PatientsWithCarotidArteryStenosis
Inpatientswithsymptomaticcarotidstenosis(includingrecent
carotidendarterectomy),werecommendlongtermantiplatelet
therapywithclopidogrel(75mgoncedaily)oraspirin
extendedreleasedipyridamole(25mg/200mgbid)oraspirin
(75100mgoncedaily)overnoantiplatelettherapy(Grade1A).
Wesuggesteitherclopidogrel(75mgoncedaily)oraspirin
extendedreleasedipyridamole(25mg/200mgbid)overaspirin
(75100mg)(Grade2B).

EndorsingOrganizations
Thisguidelinehasreceivedtheendorsementofthe
followingorganizations:
AmericanAssociationforClinicalChemistry
AmericanCollegeofClinicalPharmacy
AmericanSocietyofHealthSystemPharmacists
AmericanSocietyofHematology
InternationalSocietyofThrombosisandHemostasis

AcknowledgementofSupport
TheACCPappreciatesthesupportofthefollowingorganizations
forsomepartoftheguidelinedevelopmentprocess:
BayerScheringPharmaAG
NationalHeart,Lung,andBloodInstitute(GrantNo.R13HL104758)
Witheducationalgrantsfrom

BristolMyersSquibbandPfizer,Inc.
CanyonPharmaceuticals,and
sanofiaventisU.S.
Althoughtheseorganizationssupportedsomeportionofthedevelopment
oftheguidelines,theydidnotparticipateinanymannerwiththescope,
panelselection,evidencereview,development,manuscriptwriting,
recommendationdraftingorgrading,voting,orreview.Supportersdidnot
seetheguidelinesuntiltheywerepublished.