Optimizing medications for peripheral artery disease

How to manage stable peripheral artery disease (PAD)? ㅡ Now that Xarelto (rivaroxaban) is approved for this use. Think of managing peripheral artery disease (PAD) as similar to coronary artery disease. Plaque buildup puts peripheral artery disease (PAD) patients at high risk of complications, such as cardiovascular (CV) events or limb amputation. And they may develop symptoms such as, claudication or pain that reduces walking distance and quality of life.

Emphasize lifestyle changes in peripheral artery disease (PAD) patients. If needed, start with smoking cessation, it lowers risk of cardiovascular events, amputations, and death. And smoking may shorten walking times and accelerate progression of peripheral artery disease (PAD). Strongly encourage exercise to reduce pain and increase walking distance. A structured program (cardiac rehabilitation also called cardiac rehab, etc) seems to help most, it may increase walking distance by about the length of a football field. Stress proper foot care especially in peripheral artery disease patients with diabetes.

Focus on cardiovascular risks such as hypertension, dyslipidemia, and diabetes. For example, suggest a high-intensity statin (atorvastatin 80 mg/day, etc). Recommend aspirin 81 mg/day OR clopidogrel 75 mg/day to reduce cardiovascular risk in symptomatic PAD. Expect DUAL antiplatelets to be saved for after procedures, such as a few months after a peripheral artery stent. But other antithrombotics aren't as clear-cut. Adding Xarelto 2.5 mg BID to low-dose aspirin for 2 years prevents a stroke, heart attack, or CV death in about 1 in 50 peripheral artery disease (PAD) patients, and prevents an amputation in about 1 in 150 patients. On the other hand, the combination leads to an additional major bleed in about 1 in 100 peripheral artery disease (PAD) patients. Plus Xarelto is very expensive.Assess patient preferences. Suggest saving Xarelto for the rare peripheral artery disease (PAD) patient who's adherent to optimized CV medications AND has low bleeding risk.

Don't jump to medications just to improve walking distance. For example, cilostazol (Pletaal) has only a fraction of the benefit seen with structured exercise and pentoxifylline (Trental) doesn't seem better than placebo.

References

• Kithcart, A.P. and Beckman, J.A. (2018). ACC/AHA Versus ESC Guidelines for Diagnosis and Management of Peripheral Artery Disease. Journal of the American College of Cardiology, [online] 72(22), pp.2789–2801. Available at: https://www.sciencedirect.com/science/article/pii/S0735109718386716

  Aboyans, V., Ricco, and others. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). European Heart Journal, [online] 39(9), pp.763–816. Available at: https://academic.oup.com/eurheartj/article/39/9/763/4095038

  Gerhard-Herman, and others. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 69(11), 1465–1508. https://doi.org/10.1016/j.jacc.2016.11.008

  Anand SS, Bosch J, Eikelboom JW, and others. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial. Lancet. 2018 Jan 20;391(10117):219-229. doi: 10.1016/S0140-6736(17)32409-1. Epub 2017 Nov 10. PMID: 29132880. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32409-1/fulltext