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Antiplatelet and anticoagulant therapy in vascular disease

Every patient with symptomatic peripheral arterial disease receives a single antiplatelet (clopidogrel or aspirin) and a high-intensity statin; in high-risk patients a "vascular" dose of rivaroxaban — 2.5 mg twice daily with aspirin — is added, proven in COMPASS in stable disease and in VOYAGER PAD after revascularisation; after endovascular treatment dual antiplatelet therapy is given for a short period, and triple therapy without a reason is avoided.

לקריאה בעברית

Why it matters in the exam

The dual goal is to prevent cardiac and cerebral events (the main causes of death in vascular patients) and to prevent limb events — bypass or stent occlusion, acute ischaemia and amputation. In symptomatic disease a single antiplatelet is the basis, and clopidogrel 75 mg daily is slightly superior to aspirin (CAPRIE). In asymptomatic disease antiplatelet therapy is not given routinely, unless there is another reason. The COMPASS trial (2017) showed that in patients with stable coronary or peripheral disease, adding rivaroxaban 2.5 mg twice daily to aspirin lowered cardiac and limb events, though bleeding increased; VOYAGER PAD (2020) showed a similar benefit after leg revascularisation. The decision is matched to the patient's bleeding risk.

Rules by situation: after infrainguinal endovascular treatment — dual antiplatelet therapy (aspirin and clopidogrel) for 1–6 months, then a single agent; after vein bypass — antiplatelet therapy; after carotid endarterectomy (CEA) — aspirin or clopidogrel, and after carotid stenting (CAS) — dual antiplatelet therapy for at least 1 month. Disease with atrial fibrillation requires anticoagulation, and then prolonged addition of antiplatelets is usually avoided because of bleeding. High-intensity statin for all, with an LDL target below 55 mg/dL (1.4 mmol/L) and a reduction of at least 50% according to ESC. Cilostazol improves walking distance in claudication, but is contraindicated in a patient with heart failure. Aspirin is usually continued through vascular surgery. In arterial surgery, before clamping the artery, intravenous unfractionated heparin is given.

Smoking cessation is the single most important treatment for preserving the limb and the bypass, and every drug treatment complements it rather than replacing it.

Key points

• Single antiplatelet and statin for every symptomatic patient.
• COMPASS and VOYAGER PAD — vascular dose with aspirin.
• Dual antiplatelet therapy briefly after endovascular treatment.
• LDL below 55 mg/dL.
• Smoking cessation above all.

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Sources

• ESVS Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases, 2023 — Recommendations by vascular territory
• ESC Guidelines for the management of peripheral arterial and aortic diseases, 2024 — Antithrombotic and lipid-lowering therapy
• Bonaca et al., VOYAGER PAD, N Engl J Med, 2020 — Rivaroxaban in peripheral artery disease after revascularization

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.