What is the recommended Dual Antiplatelet Therapy (DAPT) regimen for patients with Peripheral Artery Disease (PAD)?

Recommended DAPT Regimen for Peripheral Artery Disease (PAD)

For most patients with PAD, single antiplatelet therapy (SAPT) is recommended rather than DAPT, except in specific post-revascularization scenarios where DAPT is appropriate for a limited time. 1

Antithrombotic Therapy Based on PAD Clinical Presentation

Asymptomatic PAD

• Single antiplatelet therapy is reasonable (Class 2a recommendation)
  • Aspirin 75-100 mg daily 1
  • Not routinely recommended in patients without other cardiovascular risk factors 1
  • May be considered in asymptomatic PAD patients with diabetes 1

Symptomatic PAD (Without Recent Revascularization)

• First-line therapy:
  • Single antiplatelet therapy with clopidogrel 75 mg daily (preferred over aspirin) 1
  • Alternative: Aspirin 75-160 mg daily 1
• For high-risk patients (with high ischemic risk and non-high bleeding risk):
  • Combination of low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) 1
  • High-risk features include: previous amputation, chronic limb-threatening ischemia, previous revascularization, heart failure, diabetes, multi-vascular disease, or moderate kidney dysfunction 1

After Revascularization

1. After endovascular revascularization:

   • DAPT with aspirin plus clopidogrel for 1-6 months 1
   • Then transition to single antiplatelet therapy long-term 1
   • Alternative for high-risk patients: Low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) 1

2. After surgical revascularization with prosthetic graft:

   • DAPT with aspirin plus clopidogrel may be reasonable for at least 1 month 1
   • Then transition to single antiplatelet therapy long-term 1
   • Alternative for high-risk patients: Low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) 1

Important Considerations and Caveats

• Long-term DAPT is NOT recommended for routine management of PAD 1
• Oral anticoagulant monotherapy is NOT recommended for PAD unless there's another indication (e.g., atrial fibrillation) 1
• Ticagrelor is not recommended for routine use in PAD 1
• Vorapaxar added to existing antiplatelet therapy has uncertain benefit 1
• Bleeding risk assessment is crucial before initiating any antithrombotic therapy

Special Situations

Patients Requiring Long-term Anticoagulation

• For patients with PAD who require anticoagulation for another indication (e.g., atrial fibrillation):
  • Single oral anticoagulant (OAC) monotherapy is preferred if bleeding risk is high 1
  • Adding single antiplatelet therapy to OAC is reasonable if bleeding risk is not high, especially after revascularization 1

Acute Limb Ischemia

• Immediate systemic anticoagulation with unfractionated heparin 1
• Reperfusion therapy (surgical preferred over thrombolysis) 1

Evidence Quality and Evolving Practice

The 2024 guidelines from both ESC and ACC/AHA represent the most current evidence and have strengthened recommendations for:

1. Single antiplatelet therapy as the mainstay for most PAD patients
2. Clopidogrel preference over aspirin in symptomatic PAD
3. The role of low-dose rivaroxaban plus aspirin in high-risk patients
4. Limited duration DAPT after revascularization

While some older studies suggested potential mortality benefits with DAPT 2, the most recent guidelines prioritize a more nuanced approach that balances antithrombotic efficacy with bleeding risk.

Common Pitfalls to Avoid

• Using long-term DAPT in stable PAD patients without recent revascularization
• Failing to transition from DAPT to SAPT after the appropriate post-revascularization period
• Not considering the combination of low-dose rivaroxaban plus aspirin in high-risk patients
• Using oral anticoagulants alone for PAD without another indication
• Overlooking bleeding risk assessment before initiating antithrombotic therapy