Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Treatment Options for Peripheral Artery Disease

N Engl J Med; 2017 Jan 5; Hiatt, Fowkes, et al

Publish date:

Ticagrelor was not shown to be superior to clopidogrel for the reduction of cardiovascular (CV) events in patients with symptomatic peripheral artery disease, according to a recent study. In this double-blind trial, 13,885 patients with symptomatic peripheral artery disease (median age 66 years, 72% men) were randomly assigned to receive monotherapy with ticagrelor (90 mg twice daily) or clopidogrel (75 mg once daily). Patients were eligible if they had an ankle-brachial index (ABI) of 0.80 or less or had undergone previous revascularization of the lower limbs. Researchers found:

  • The primary efficacy end point (composite of adjusted CV death, MI, or ischemic stroke) occurred in 751 or 6,930 patients (10.8%) receiving ticagrelor and in 740 or 6,955 (10.6%) receiving clopidogrel (HR, 1.02).
  • In each group, acute limb ischemia occurred in 1.7% of the patients (HR, 1.03).
  • Major bleeding also occurred at similar rates among the patients in each group (HR, 1.6%).

Citation:

Hiatt WR, Fowkes FG, Heizer G, et al. Ticagrelor versus clopidogrel in symptomatic peripheral artery disease. N Engl J Med. 2017;376:32-40. doi:10.1056/NEJMoa1611688.

Commentary:

Patients with peripheral artery disease are at high risk of developing other vascular diseases including MI, stroke and cardiovascular death. Aspirin has been shown to decrease the incidence of cardiovascular events by 12% vs placebo in patients with peripheral vascular disease.1 In the CAPRIE study, clopidogrel was compared to aspirin in patients with coronary artery disease, peripheral artery disease, and cerebrovascular disease. The trial showed a significant benefit for clopidogrel over aspirin, and that benefit was most pronounced in patients with PAD.2 In the CHARISMA trial, aspirin plus clopidogrel was compared to aspirin alone in patients with atherosclerosis, and there was no benefit for dual therapy but there was an increased risk of bleeding.3 The present study shows no benefit in decreasing CV outcomes in patients with PAD on ticagrelor, a potent platelet inhibitor, vs clopidogrel. —Neil Skolnik, MD

  1. Berger JS, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA. 2009;301:1909-19. doi:10.1001/jama.2009.623.
  2. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348:1329-39.
  3. Bhatt DL, Fox KAA, Hacke W, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354:1706-17. doi:10.1056/NEJMoa060989.

This Week's Must Reads

Must Reads in Cardiology

Consumption of SSBs & Risk of Mortality, Circulation; ePub 2019 Mar 18; Malik, et al

Dietary Cholesterol or Egg Consumption & CVD, JAMA; 2019 Mar 19; Zhong, Van Horn, et al

Physical Activity & Incidence of CHD & CVD in Women, JAMA Netw Open; ePub 2019 Mar 15; LaCroix, et al

Intensive BP Control in Adults with Hypertension Who Smoke, JAMA Netw Open; ePub 2019 Mar 8; Scarpa, et al