1 Department of Medicine, University of Toronto, Toronto, ON, Canada.
2 Department of Medicine, University of Calgary, Calgary, AB, Canada.
Vasc Med. 2019 Apr;24(2):132-140. doi: 10.1177/1358863X18820123. Epub 2019 Feb 24.
Patients with peripheral artery disease (PAD) are at high risk for ischemic cardiovascular complications. While single antiplatelet therapy (SAPT), predominantly aspirin, has long been the standard antithrombotic treatment in stable PAD, there have now been greater than 40,000 PAD patients randomized to varying antiplatelet and/or anticoagulant regimens. In this review, we provide a summary of the current evidence for antithrombotics in stable PAD, focusing on the rates of major adverse cardiovascular events (MACE), major adverse limb events (MALE), and major bleeding. SAPT has a limited role in the treatment of asymptomatic PAD, particularly in the absence of concomitant coronary artery disease. In symptomatic PAD, SAPT is effective in preventing MACE, though treatment with a thienopyridine appears marginally superior to aspirin. Dual antiplatelet therapy (DAPT) suggests benefit over SAPT in reducing MACE and MALE, though studies to date are not conclusive and/or are associated with excess major bleeding. Combining moderate to high intensity vitamin K antagonists with antiplatelet therapy does not reduce MACE or MALE and increases life-threatening bleeding. Rivaroxaban 2.5 mg BID in addition to aspirin reduces the incidence of both MACE and MALE as compared to aspirin alone, without increasing life-threatening bleeding. This regimen is associated with a reduced severity of MALE when it does occur. Comparisons across antithrombotic trials in PAD are challenging given the heterogeneity of patient populations and the differing assessment of outcomes. The vascular medicine practitioner can reduce ischemic cardiac and limb events, as well as minimize life-threatening bleeding, by choosing the optimal antithrombotic regimen in their PAD patients.
患有外周动脉疾病（PAD）的患者存在发生缺血性心血管并发症的高危风险。虽然单一抗血小板治疗（SAPT），主要是阿司匹林，长期以来一直是稳定型 PAD 的标准抗血栓治疗，但现在已经有超过 40000 名 PAD 患者被随机分配到不同的抗血小板和/或抗凝治疗方案中。在这篇综述中，我们提供了稳定型 PAD 中抗血栓药物的当前证据总结，重点介绍了主要不良心血管事件（MACE）、主要不良肢体事件（MALE）和大出血的发生率。SAPT 在无症状 PAD 的治疗中作用有限，特别是在没有同时存在冠状动脉疾病的情况下。在有症状的 PAD 中，SAPT 可有效预防 MACE，但噻氯匹定治疗似乎比阿司匹林略优。双重抗血小板治疗（DAPT）表明在降低 MACE 和 MALE 方面优于 SAPT，但迄今为止的研究尚不确定，且/或与大出血增加有关。将中等至高强度维生素 K 拮抗剂与抗血小板治疗联合使用并不能降低 MACE 或 MALE，反而会增加危及生命的出血。与单独使用阿司匹林相比，每天两次给予 2.5 毫克利伐沙班加用阿司匹林可降低 MACE 和 MALE 的发生率，而不会增加危及生命的出血。当 MALE 确实发生时，这种方案与 MALE 严重程度的降低有关。由于患者人群的异质性和结果评估的不同，在 PAD 中的抗血栓试验之间进行比较具有挑战性。血管医学从业者可以通过为 PAD 患者选择最佳的抗血栓治疗方案，降低缺血性心脏和肢体事件的发生，同时最大限度地减少危及生命的出血。
