What are the recommended discharge medications for a patient with peripheral arterial disease (PAD)?

Discharge Medications for Peripheral Arterial Disease

Antiplatelet Therapy (Mandatory)

All patients with symptomatic PAD must be discharged on single antiplatelet therapy—specifically clopidogrel 75 mg daily as the preferred agent, or aspirin 75-160 mg daily as an acceptable alternative. 1, 2

• Clopidogrel 75 mg daily is the first-choice antiplatelet agent based on superior efficacy demonstrated in the CAPRIE trial, showing a 24% relative risk reduction in cardiovascular events compared to aspirin specifically in PAD patients 2
• Aspirin 75-325 mg daily (optimally 75-160 mg) is recommended if clopidogrel is contraindicated, unavailable, or not tolerated 1, 2
• For asymptomatic PAD patients with ABI ≤0.90, antiplatelet therapy is reasonable to reduce MI, stroke, and vascular death 1, 2

Critical caveat: Avoid dual antiplatelet therapy (aspirin plus clopidogrel) in most PAD patients—it provides no additional cardiovascular benefit over single therapy and significantly increases major bleeding risk 2. Dual antiplatelet therapy may only be considered in highly selected patients at very high cardiovascular risk who are not at increased bleeding risk 1

Do not combine antiplatelet agents with warfarin unless there is a separate compelling indication (e.g., atrial fibrillation)—this combination is potentially harmful due to increased major bleeding without cardiovascular benefit 1, 2

Lipid Management (Mandatory)

All PAD patients must be discharged on high-intensity statin therapy regardless of baseline cholesterol levels, with a target LDL-C <70 mg/dL. 2, 3, 4

• Statins reduce the incidence of intermittent claudication, improve exercise duration, and reduce cardiovascular mortality in PAD patients 3, 4
• The LDL-C target of <70 mg/dL applies to all PAD patients given their very high cardiovascular risk status 2

Blood Pressure Management (Mandatory)

Discharge all PAD patients on antihypertensive therapy with a target BP <140/90 mmHg (or <130/80 mmHg if diabetes or chronic kidney disease is present). 2

• ACE inhibitors or ARBs are the preferred first-line antihypertensive agents for cardiovascular protection in PAD 2
• Beta-blockers are NOT contraindicated in PAD—they are safe, effective antihypertensives and should be prescribed if coronary artery disease coexists 1, 2
• The outdated concern that beta-blockers worsen claudication has been disproven; do not withhold them unnecessarily 2

Diabetes Management (If Applicable)

Optimize glycemic control with target HbA1C <7% using glucose-lowering agents with proven cardiovascular benefits (GLP-1 receptor agonists or SGLT-2 inhibitors preferred). 1, 5

• Prioritize agents with proven cardiovascular benefits over those without such evidence 1
• Avoid hypoglycemia, which can worsen outcomes 1
• Mandatory foot care education: appropriate footwear, daily foot inspection, skin cleansing, topical moisturizers, and urgent treatment of any lesions 2

Smoking Cessation Pharmacotherapy (If Applicable)

All smokers with PAD must be offered pharmacological therapy for smoking cessation at discharge—varenicline, bupropion, or nicotine replacement therapy are equally effective options. 1, 2

• Smoking cessation is the single most important intervention to prevent PAD progression 1
• Provide both behavioral counseling and pharmacotherapy, not just advice to quit 1

Symptom Relief for Intermittent Claudication

Add cilostazol 100 mg twice daily if claudication persists despite 3 months of optimal medical therapy and supervised exercise therapy. 1, 2

• Cilostazol is a phosphodiesterase-3 inhibitor that improves symptoms and increases walking distance 1
• It should be added to baseline antiplatelet therapy, not used as a substitute 2
• Contraindication: Do not prescribe cilostazol in patients with heart failure of any severity 1

Pentoxifylline is NOT recommended—it has marginal efficacy and is not supported by current guidelines 6

Post-Revascularization Antiplatelet Therapy

Continue long-term single antiplatelet therapy (aspirin 75-100 mg daily or clopidogrel 75 mg daily) after any revascularization procedure (endovascular or surgical bypass). 2

• This applies to both percutaneous transluminal angioplasty with or without stenting and bypass surgery 2
• Do not routinely use dual antiplatelet therapy post-revascularization unless there is a specific high-risk indication 1

Medications to AVOID

• Warfarin monotherapy or warfarin plus antiplatelet therapy (unless separate indication exists)—no benefit and increased bleeding risk 1, 2
• Ticagrelor—not routinely recommended for PAD 1
• Homocysteine-lowering therapy (folic acid, vitamin B12)—not established as effective even with elevated homocysteine >14 micromoles/L 1, 2
• Dual antiplatelet therapy (aspirin + clopidogrel)—increases bleeding without additional cardiovascular benefit in most PAD patients 2

Mandatory Non-Pharmacologic Discharge Instructions

Prescribe supervised exercise therapy: 30-45 minutes per session, at least 3 times weekly, for minimum 12 weeks. 1

• Supervised exercise training is as effective as revascularization for improving claudication symptoms 1
• Unsupervised exercise programs are not well-established as effective 1