Should a patient with severe peripheral vascular disease and essential thrombocytosis be stepped down from dual antiplatelet therapy to single antiplatelet therapy (aspirin monotherapy) after a recent traumatic injury?

Recommendation for Antiplatelet Therapy in This Patient

This patient should be stepped down from dual antiplatelet therapy (aspirin + clopidogrel) to single antiplatelet therapy with aspirin monotherapy (75-100 mg daily), given her remote revascularization (>5 years ago), absence of current claudication, well-controlled essential thrombocytosis, and recent traumatic injury with increased bleeding vulnerability. 1

Rationale Based on Current Guidelines

Time Since Revascularization

• Long-term dual antiplatelet therapy is not recommended in patients with peripheral arterial disease (PAD). 1 The 2024 ESC guidelines explicitly state that "long-term DAPT in patients with PAD is not recommended." 1
• After endovascular or surgical revascularization, dual antiplatelet therapy is reasonable for only 1-6 months post-procedure. 1 This patient's most recent grafting was in 2019 (>5 years ago), placing her well beyond any window where dual therapy provides benefit.
• The 2024 ACC/AHA guidelines note that "the benefit of dual antiplatelet therapy is uncertain" in patients with symptomatic PAD without recent revascularization. 1

Current Clinical Status

• She is asymptomatic from a vascular standpoint (no claudication symptoms), which further supports de-escalation. 1
• Her essential thrombocytosis is well-controlled on hydroxyurea with platelets at 291 × 10⁹/L, which is within normal range. 2
• The recent rib fractures create a period of increased bleeding vulnerability, making the bleeding risk of dual therapy particularly concerning. 1

Essential Thrombocytosis Considerations

• For patients with essential thrombocytosis at low-to-intermediate thrombotic risk (age <60 years without prior thrombosis), aspirin monotherapy (81-100 mg daily) is the standard recommendation. 2
• At age 74 with JAK2-positive disease and well-controlled platelets on hydroxyurea, she is already receiving appropriate cytoreductive therapy. 2, 3
• The combination of aspirin plus hydroxyurea addresses both her thrombotic risk from essential thrombocytosis and her history of peripheral vascular disease. 2

Specific Recommendation

Discontinue clopidogrel and continue aspirin 81-100 mg daily. 1, 4

Why Aspirin Over Clopidogrel?

• Both aspirin (75-160 mg daily) and clopidogrel (75 mg daily) are Class I recommendations for symptomatic PAD. 1
• However, aspirin is specifically recommended for essential thrombocytosis, making it the logical choice for monotherapy in this patient with dual pathology. 2
• Clopidogrel may have a modest advantage over aspirin in PAD alone 1, but this patient's essential thrombocytosis tips the balance toward aspirin.

Important Caveats

Bleeding Risk Assessment

• The patient's recent trauma with rib fractures represents a temporary period of increased bleeding risk that strongly favors de-escalation now rather than continuing dual therapy. 1
• Even without the trauma, the bleeding risk of long-term dual antiplatelet therapy outweighs benefits in patients without recent revascularization. 1

Monitoring After De-escalation

• Assess for recurrence of claudication symptoms at follow-up visits (at least annually). 1
• Continue monitoring platelet counts and adjust hydroxyurea as needed to maintain platelets <450 × 10⁹/L. 2
• If claudication recurs or new vascular symptoms develop, reassess with ankle-brachial index and consider vascular imaging. 1

When Dual Therapy Would Be Indicated

The only scenarios where dual antiplatelet therapy would be appropriate for this patient include: 1

• Within 1-6 months of new endovascular revascularization (aspirin + clopidogrel)
• If she develops atrial fibrillation requiring anticoagulation, then single antiplatelet therapy (aspirin) added to anticoagulation would be reasonable if bleeding risk is not high 1
• Consideration of aspirin + low-dose rivaroxaban 2.5 mg twice daily if she develops recurrent symptomatic PAD or requires future revascularization, though this increases bleeding risk 1

Alternative: Rivaroxaban Plus Aspirin

• The 2024 guidelines support low-dose rivaroxaban (2.5 mg twice daily) plus aspirin to reduce major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in symptomatic PAD. 1, 4
• However, this combination increases major bleeding risk and is not appropriate given her recent trauma and current asymptomatic status. 1
• This option could be reconsidered if she develops recurrent symptomatic disease in the future, once her rib fractures have healed and bleeding risk normalizes. 1