What is the recommended Dual Anti-Platelet Therapy (DAPT) regimen for patients after Peripheral Artery Disease (PAD) angioplasty?

From the Guidelines

Dual Anti-Platelet Therapy (DAPT) with a P2Y12 antagonist and low-dose aspirin for at least 1 to 6 months is a reasonable approach after endovascular revascularization for PAD, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. The choice of antiplatelet therapy after PAD angioplasty is guided by the goal of reducing the risk of major adverse cardiac events (MACE) and major adverse limb events (MALE) while minimizing the risk of bleeding complications.

• The 2024 guideline recommends single antiplatelet therapy with clopidogrel alone (75 mg daily) or aspirin alone (range, 75-325 mg daily) to reduce the risk of MACE in patients with symptomatic PAD 1.
• However, after endovascular or surgical revascularization for PAD, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin is recommended to reduce the risk of MACE and MALE 1.
• For patients undergoing endovascular revascularization, dual antiplatelet therapy with a P2Y12 antagonist and low-dose aspirin may be considered for a limited duration, typically 1 to 6 months, based on individual patient risk factors and the complexity of the procedure 1.
• It is essential to assess the patient's bleeding risk before initiating DAPT and to consider the use of proton pump inhibitors in patients with high bleeding risk or a history of gastrointestinal bleeding.
• The decision to extend DAPT beyond 6 months should be made on a case-by-case basis, taking into account the patient's overall clinical profile, including the presence of complex lesions, stent placement, or a history of stent thrombosis 1.

From the Research

Dual Anti-Platelet Therapy (DAPT) for Post PAD Angioplasty

• The recommended DAPT regimen for patients after Peripheral Artery Disease (PAD) angioplasty is at least four weeks of DAPT with aspirin and clopidogrel after infrainguinal stent implantation 2.
• Stenting below-the-knee arteries is often followed by a longer period of DAPT, but no specific evidence is available 2.
• Rivaroxaban (2.5 mg b.i.d.) plus aspirin (100 mg daily) has shown significant benefit for PAD patients in terms of total mortality and cardiovascular mortality, and may be considered for secondary prevention of symptomatic PAD patients 2.
• DAPT with ticagrelor 60 mg b.i.d. and aspirin provides a significant major adverse cardiovascular events reduction in symptomatic PAD patients and may be considered in PAD patients with prior myocardial infarction 2.

Comparison of DAPT Regimens

• A meta-analysis of studies comparing DAPT vs single antiplatelet therapy (SAPT) with aspirin in patients with PAD found that DAPT was associated with a significant reduction in mortality and repeat peripheral revascularizations, with no significant increase in bleeding complications 3.
• The use of prasugrel or ticagrelor plus aspirin as DAPT has demonstrated greater efficacy than clopidogrel in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) 4.
• Triple antiplatelet therapy (TAPT) with cilostazol, aspirin, and clopidogrel has been shown to significantly improve high on-treatment platelet reactivity and reduce major adverse cardiovascular events in patients undergoing PCI 5.

Duration of DAPT

• The optimal duration of DAPT after PAD angioplasty is uncertain, but short-term DAPT of 3-6 months or even 1 month in high-bleeding risk patients may be equivalent in terms of efficacy and effectiveness compared to long-term DAPT 6.
• Prolonged DAPT beyond 12 months reduces stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates but increases bleeding risk 6.