Peter A Soden1, Sara L Zettervall1, Klaas H J Ultee1, Bruce E Landon2, A James O'Malley3, Philip P Goodney4, Randall R DeMartino5, Shipra Arya6, Marc L Schermerhorn7. 1. Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. 2. Division of General Medicine and Primary Care, Department of Health Care Policy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. 3. Department of Biomedical Data Science and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. 4. Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. 5. Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. 6. Division of Vascular Surgery, Emory University School of Medicine, Atlanta, and Atlanta VA Medical Center, Decatur, Ga. 7. Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
Abstract
BACKGROUND: Dual antiplatelet therapy (DAPT) after coronary stenting prolongs survival by preventing both in-stent thrombosis and other cardiovascular atherothrombotic events. Patients with peripheral artery disease (PAD) typically have a heavy burden of unrevascularized coronary artery disease and also stand to benefit from increased atherothrombotic protection with DAPT. The potential benefit of DAPT compared with aspirin alone in patients with PAD is not well described. METHODS: We identified all patients undergoing an initial elective lower extremity revascularization (bypass or endovascular) from 2003 to 2016 in the Vascular Quality Initiative registry discharged on aspirin or aspirin plus a thienopyridine antiplatelet agent (DAPT). We first estimated models predicting the likelihood of receiving DAPT and then used inverse probability weighting to account for baseline differences in the likelihood of receiving DAPT and compared late survival. For sensitivity analysis, we also performed Cox proportion hazard modeling on the unweighted cohorts and generated adjusted survival curves. RESULTS: We identified 57,041 patients undergoing lower extremity revascularization (28% bypass). Of 15,985 bypasses (69% for critical limb ischemia [CLI]), 38% were discharged on DAPT. Of 41,056 endovascular interventions (39% for CLI), 69% were discharged on DAPT. Analyses using inverse probability weighting demonstrated a small survival benefit to DAPT at 1 year for bypass (93% vs 92% [P = .001]) and endovascular interventions (93% vs 92% [P = .005]) that was sustained through 5 years of follow-up (bypass, 80% vs 78% [P = .004]; endovascular, 76% vs 73% [P = .002]). When stratified by severity of PAD, DAPT had a survival benefit for patients with CLI undergoing bypass (5 years, 70% vs 66% [P = .04]) and endovascular intervention (5 years, 71% vs 67% [P = .01]) but not for patients with claudication (bypass, 89% vs 88% [P = .36]; endovascular, 87% vs 85% [P = .46]). The protective effect of DAPT was similar when using Cox proportional hazard models after bypass (hazard ratio, 0.81 [95% confidence interval, 0.72-0.90]) and endovascular intervention (hazard ratio, 0.89 [95% confidence interval, 0.83-0.95]). CONCLUSIONS: DAPT at time of discharge was associated with prolonged survival for patients with CLI undergoing lower extremity revascularization but not for those with claudication. Further research is needed to quantify the risks associated with DAPT and to identify subgroups at increased risk of thrombotic and bleeding complications to guide medical management of patients with PAD.
BACKGROUND: Dual antiplatelet therapy (DAPT) after coronary stenting prolongs survival by preventing both in-stent thrombosis and other cardiovascular atherothrombotic events. Patients with peripheral artery disease (PAD) typically have a heavy burden of unrevascularized coronary artery disease and also stand to benefit from increased atherothrombotic protection with DAPT. The potential benefit of DAPT compared with aspirin alone in patients with PAD is not well described. METHODS: We identified all patients undergoing an initial elective lower extremity revascularization (bypass or endovascular) from 2003 to 2016 in the Vascular Quality Initiative registry discharged on aspirin or aspirin plus a thienopyridine antiplatelet agent (DAPT). We first estimated models predicting the likelihood of receiving DAPT and then used inverse probability weighting to account for baseline differences in the likelihood of receiving DAPT and compared late survival. For sensitivity analysis, we also performed Cox proportion hazard modeling on the unweighted cohorts and generated adjusted survival curves. RESULTS: We identified 57,041 patients undergoing lower extremity revascularization (28% bypass). Of 15,985 bypasses (69% for critical limb ischemia [CLI]), 38% were discharged on DAPT. Of 41,056 endovascular interventions (39% for CLI), 69% were discharged on DAPT. Analyses using inverse probability weighting demonstrated a small survival benefit to DAPT at 1 year for bypass (93% vs 92% [P = .001]) and endovascular interventions (93% vs 92% [P = .005]) that was sustained through 5 years of follow-up (bypass, 80% vs 78% [P = .004]; endovascular, 76% vs 73% [P = .002]). When stratified by severity of PAD, DAPT had a survival benefit for patients with CLI undergoing bypass (5 years, 70% vs 66% [P = .04]) and endovascular intervention (5 years, 71% vs 67% [P = .01]) but not for patients with claudication (bypass, 89% vs 88% [P = .36]; endovascular, 87% vs 85% [P = .46]). The protective effect of DAPT was similar when using Cox proportional hazard models after bypass (hazard ratio, 0.81 [95% confidence interval, 0.72-0.90]) and endovascular intervention (hazard ratio, 0.89 [95% confidence interval, 0.83-0.95]). CONCLUSIONS:DAPT at time of discharge was associated with prolonged survival for patients with CLI undergoing lower extremity revascularization but not for those with claudication. Further research is needed to quantify the risks associated with DAPT and to identify subgroups at increased risk of thrombotic and bleeding complications to guide medical management of patients with PAD.
Authors: Per Olav Vandvik; A Michael Lincoff; Joel M Gore; David D Gutterman; Frank A Sonnenberg; Pablo Alonso-Coello; Elie A Akl; Maarten G Lansberg; Gordon H Guyatt; Frederick A Spencer Journal: Chest Date: 2012-02 Impact factor: 9.410
Authors: Andrew W Bradbury; Donald J Adam; Jocelyn Bell; John F Forbes; F Gerry R Fowkes; Ian Gillespie; Charles Vaughan Ruckley; Gillian M Raab Journal: J Vasc Surg Date: 2010-05 Impact factor: 4.268
Authors: Ehrin J Armstrong; David R Anderson; Khung-Keong Yeo; Gagan D Singh; Heejung Bang; Ezra A Amsterdam; Julie A Freischlag; John R Laird Journal: J Vasc Surg Date: 2015-04-08 Impact factor: 4.268
Authors: K Moshfegh; M Redondo; F Julmy; W A Wuillemin; M U Gebauer; A Haeberli; B J Meyer Journal: J Am Coll Cardiol Date: 2000-09 Impact factor: 24.094
Authors: Marc P Bonaca; Deepak L Bhatt; Marc Cohen; Philippe Gabriel Steg; Robert F Storey; Eva C Jensen; Giulia Magnani; Sameer Bansilal; M Polly Fish; Kyungah Im; Olof Bengtsson; Ton Oude Ophuis; Andrzej Budaj; Pierre Theroux; Mikhail Ruda; Christian Hamm; Shinya Goto; Jindrich Spinar; José Carlos Nicolau; Robert G Kiss; Sabina A Murphy; Stephen D Wiviott; Peter Held; Eugene Braunwald; Marc S Sabatine Journal: N Engl J Med Date: 2015-03-14 Impact factor: 91.245
Authors: Natasha Chinai; Graeme K Ambler; Bethany G Wardle; Dafydd Locker; Dave Bosanquet; Nimit Goyal; Christopher Chick; Robert J Hinchliffe; Christopher P Twine Journal: PLoS One Date: 2020-06-11 Impact factor: 3.240