This guideline focuses on antithrombotic drug therapies for primary and secondary prevention of cardiovascular disease as well as for the relief of lower-extremity symptoms and critical ischemia in persons with peripheral arterial disease (PAD).
The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.
The most important of our 20 recommendations are as follows. In patients aged ≥ 50 years with asymptomatic PAD or asymptomatic carotid stenosis, we suggest aspirin (75-100 mg/d) over no therapy (Grade 2B) for the primary prevention of cardiovascular events. For secondary prevention of cardiovascular disease in patients with symptomatic PAD (including patients before and after peripheral arterial bypass surgery or percutaneous transluminal angioplasty), we recommend long-term aspirin (75-100 mg/d) or clopidogrel (75 mg/d) (Grade 1A). We recommend against the use of warfarin plus aspirin in patients with symptomatic PAD (Grade 1B). For patients undergoing peripheral artery percutaneous transluminal angioplasty with stenting, we suggest single rather than dual antiplatelet therapy (Grade 2C). For patients with refractory claudication despite exercise therapy and smoking cessation, we suggest addition of cilostazol (100 mg bid) to aspirin (75-100 mg/d) or clopidogrel (75 mg/d) (Grade 2C). In patients with critical limb ischemia and rest pain unable to undergo revascularization, we suggest the use of prostanoids (Grade 2C). In patients with acute limb ischemia due to acute thrombosis or embolism, we recommend surgery over peripheral arterial thrombolysis (Grade 1B).
Recommendations continue to favor single antiplatelet therapy for primary and secondary prevention of cardiovascular events in most patients with asymptomatic PAD, symptomatic PAD, and asymptomatic carotid stenosis. Additional therapies for relief of limb symptoms should be considered only after exercise therapy, smoking cessation, and evaluation for peripheral artery revascularization.From the Iberoamerican Cochrane Centre (Dr Alonso-Coello), CIBERESP-IIB Sant Pau, Barcelona, Spain; Angiology (Dr Bellmunt), Vascular and Endovascular Surgery Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; The Heart House (Dr McGorrian), Mater Misericordiae University Hospital, Dublin, Ireland; Departments of Medicine and Clinical Epidemiology and Biostatistics (Drs Anand and Guyatt), McMaster University, Hamilton, ON, Canada; Section Vascular Surgery (Dr Guzman), University of Manitoba, St Boniface Hospital, Winnipeg, MB, Canada; Department of Family and Preventive Medicine (Dr Criqui), University of California San Diego School of Medicine, La Jolla, CA; Department of Medicine (Dr Akl), State University of New York at Buffalo, Buffalo, NY; Norwegian Knowledge Centre for the Health Services and Department of Medicine Gjøvik (Dr Vandvik), Innlandet Hospital Trust, Gjøvik, Norway; Stanford Stroke Center (Dr Lansberg), Stanford University Medical Center, Palo Alto, CA; and Department of Medicine (Dr Spencer), McMaster University, Hamilton, ON, Canada.
Correspondence to: Frederick A. Spencer, MD, Department of Medicine, McMaster University, St Joseph’s Health Care, 50 Charlton Ave E, Hamilton, ON, L8N 4A6, Canada; e-mail: email@example.com
Author contributions: As Topic Editor, Dr Alonso-Coello oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.
Dr Alonso-Coello: contributed as Topic Editor.
Dr Bellmunt: contributed as a frontline clinician.
Dr McGorrian: contributed as a panelist.
Dr Anand: contributed as a panelist.
Dr Guzman: contributed as a panelist.
Dr Criqui: contributed as a panelist.
Dr Akl: contributed as a panelist.
Dr Vandvik: contributed as a panelist.
Dr Lansberg: contributed as a panelist.
Dr Guyatt: contributed as a panelist.
Dr Spencer: contributed as Deputy Editor.
Financial/nonfinancial disclosures: The authors of this guideline provided detailed conflict of interest information related to each individual recommendation made in this article. A grid of these disclosures is available online at http://chestjournal.chestpubs.org/content/141/2_suppl/e669S/suppl/DC1. In summary, the authors have reported to CHEST the following conflicts of interest: Dr Bullmunt received funds from Roche for a study unrelated to this guideline and received funds from Ferrer Laboratory for writing a public document related to cilostazol. Dr McGorrian has received conference travel support from Pfizer Ireland Ltd. Dr Guyatt is co-chair of the GRADE Working Group. Drs Alonso-Coello, Akl, and Vandvik are members of and prominent contributors to the GRADE Working Group. Drs Anand, Guzman, Criqui, Lansberg, and Spencer have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Role of sponsors: The sponsors played no role in the development of these guidelines. Sponsoring organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Guideline panel members, including the chair, and members of the Health & Science Policy Committee are blinded to the funding sources. Further details on the Conflict of Interest Policy are available online at http://chestnet.org.
Other contributions: We acknowledge Saurabh Kalra for his important contribution to this article, especially in the section on acute limb ischemia. We acknowledge Kristian Thorlund, PhD, for assistance on presentation of continuous outcomes. We thank John Eikelboom, MD, for his contribution of estimates of total mortality for patients on or off aspirin (primary prevention) and Sam Schulman, MD, for assistance with interpretation of bleeding definitions. We thank John Wong, MD, for assistance in identifying cost-effectiveness implications.
Endorsements: This guideline is endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the American Society of Health-System Pharmacists, the American Society of Hematology, and the International Society of Thrombosis and Hematosis.
Additional information: The supplement Tables can be found in the Online Data Supplement at http://chestjournal.chestpubs.org/content/141/2_suppl/e669S/suppl/DC1.Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants were also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).