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Currently taking oral anticoagulation medication for another condition?

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According to Bonaca et al. (2020), limb symptoms frequently develop in patients with peripheral artery disease, to include those that are post revascularization. Such symptoms range from severe claudication, which limits function, to critical limb-threatening ischemia. Patients who undergo peripheral revascularization are at high risk for subsequent vascular complications with a risk approximately 4 times as high as that among persons who have never undergone revascularization. Several observations, to include use of inhibiting thrombin-mediated activation of platelets with vorapaxar reduced the risk of acute limb ischemia in patients with stable peripheral artery disease, indicate that the risk of this complication is modifiable. Additionally, the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial showed that rivaroxaban (a selective direct factor Xa inhibitor) at a dose of 2.5 mg twice daily added to aspirin reduced ischemic risk. Additional factors, such as bleeding risk, also plays a role in the judicial use of anticoagulants. Medication treatment plans in the presence of bleeding risk factors will require additional scrutiny as the clinician and patient weigh the risks.

The decision tree used in this app was developed by the Anticoagulation Forum (Barnes, Parikh & Wirth, 2021) as an ACE Rapid Resource, called the Antithrombotic Management Following Peripheral Arterial Disease (PAD) Revascularization. The following disclaimer is posted by the AC Forum, "ACE Rapid Resources are not clinical practice guidelines; they are Anticoagulation Forum, Inc.’s best recommendations based on current knowledge, and no warranty or guaranty is expressed or implied. The content provided is for informational purposes for medical professionals only and is not intended to be used or relied upon by them as specific medical advice, diagnosis, or treatment, the determination of which remains the responsibility of the medical professionals for their patients."

All questions & possible results

TriageTitle not visible

Currently taking oral anticoagulation medication for another condition?

Select one option:

Select indication for current oral anticoagulation therapy.

*atrial fibrillation (AF)

*antiphospholipid syndrome (APS)

*venous thromboembolism (VTE treatment)

Select one option:

Long-term anticoagulation (e.g., AF, mechanical valve, APS, or extended VTE treatment)
Short-term anticoagulation (e.g., VTE initial treatment)
Dual antiplatelet therapy (DAPT) for > 1 month (e.g., acute coronary syndrome, recent DES placement in coronary or below knee arteries)

Asymptomatic PAD Without History of Revascularization Triage

Allergy to aspirin?

Select one option:

No
Yes (ASA allergy is a contraindication for DAPT. Consider clopidogrel monotherapy as an alternative.)

At increased risk of bleeding?

Bleeding Risk Factors to Consider:

Concurrent NSAID or other antiplatelet agents
History of hemorrhagic stroke, intracranial hemorrhage, or significant bleeding
Recent GI ulceration
Active malignant neoplasms at risk of bleeding
History of vascular aneurysms
History of coagulopathies/bleeding disorders
Uncontrolled hypertension (SBP > 160 mmHg)
Heavy alcohol use or esophageal varices
Acute liver or renal failure
Recent trauma or surgery

These factors represent a sampling of bleeding risk factors from validated tools (HAS-BLED, HEMORR2HAGES, IMPROVE-VTE) and the primary literature (VOYAGER-PAD, COMPASS.)

Select one option:

No
Yes (Increased bleed risk may be a contraindication for DAPT)

Is the patient already prescribed or using aspirin?

Select one option:

Possible results

Warning - Aspirin Allergy: Consider clopidogrel 75mg PO Daily

Asymptomatic PAD & Bleed Risk! Consider aspirin 81mg daily as monotherapy.

Treatment Options

If Asymptomatic - Monotherapy

Aspirin 81mg daily -OR- Clopidogrel 75mg daily

If Asymptomatic & high bleed risk - Monotherapy

Aspirin 81mg daily

Footnote

The rationale behind dual pathway inhibition is to block two different mechanisms for platelet activation to further reduce thrombotic risk. In the COMPASS Trial, the combination of rivaroxaban (a factor Xa inhibitor) and aspirin has been shown to reduce the rates of MACE and MALE (6% vs. 9%, HR 0.69, P < 0.001) versus aspirin monotherapy without increases in fatal or nonfatal bleeding or intracranial hemorrhage.
Major bleeding was increased in DPI vs. ASA (3% vs. 2%, HR 1.61, p=0.008) and was driven by increased gastrointestinal bleeding, and front-loaded in the first year (COMPASS Trial).
For more information, view the Anticoagulation Forum Rapid Resource on PAD and DPI.
Factor Xa inhibitors (rivaroxaban) blocks platelet activation by inhibition of thrombin formation, while aspirin, a COX-1 inhibitor, blocks platelet activation via inhibition of thromboxane A2.

Asymptomatic PAD: Consider aspirin 81mg daily OR Clopidogrel 75mg daily. If bleed risk, consider aspirin daily only

Treatment Options

If Asymptomatic - Monotherapy

Aspirin 81mg daily -OR- Clopidogrel 75mg daily

If Asymptomatic & high bleed risk - Monotherapy

Aspirin 81mg daily

Footnote

The rationale behind dual pathway inhibition is to block two different mechanisms for platelet activation to further reduce thrombotic risk. In the COMPASS Trial, the combination of rivaroxaban (a factor Xa inhibitor) and aspirin has been shown to reduce the rates of MACE and MALE (6% vs. 9%, HR 0.69, P < 0.001) versus aspirin monotherapy without increases in fatal or nonfatal bleeding or intracranial hemorrhage.
Major bleeding was increased in DPI vs. ASA (3% vs. 2%, HR 1.61, p=0.008) and was driven by increased gastrointestinal bleeding, and front-loaded in the first year (COMPASS Trial).
For more information, view the Anticoagulation Forum Rapid Resource on PAD and DPI.
Factor Xa inhibitors (rivaroxaban) blocks platelet activation by inhibition of thrombin formation, while aspirin, a COX-1 inhibitor, blocks platelet activation via inhibition of thromboxane A2.

Asymptomatic PAD Plus Other Indication for Anticoagulation: Continue current anticoagulation protocol as previously prescribed.

If already taking aspirin, confirm the appropriate dosage of aspirin

Warning - Aspirin Allergy & Bleed Risk! Consult a pharmacist or interventionalist for assistance.

Literature

2024 Lower Extremity Peripheral Artery Disease Guideline-at-a-Glance. J Am Coll Cardiol. 2024 Jun 18;83(24):2605-2609. — Bates KJ, Moore MM, Cibotti-Sun M.
2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jun 11;149(24):e1313-e1410. — Gornik HL, et al.
Rivaroxaban in Peripheral Artery Disease after Revascularization. N Engl J Med. 2020 May 21;382(21):1994-2004. — Bonaca MP, Bauersachs RM, Anand SS, Debus ES, Nehler MR, Patel MR, Fanelli F, Capell WH, Diao L, Jaeger N, Hess CN, Pap AF, Kittelson JM, Gudz I, Mátyás L, Krievins DK, Diaz R, Brodmann M, Muehlhofer E, Haskell LP, Berkowitz SD, Hiatt WR.
Antiplatelet Therapy For High Bleeding Risk Patients Undergoing PCI. 25 April 2020. — American College of Cardiology
Bleeding complications with dual antiplatelet therapy among patients with stable vascular disease or risk factors for vascular disease: results from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial. Circulation. 2010 Jun 15;121(23):2575-83. — Berger PB, Bhatt DL, Fuster V, Steg PG, Fox KA, Shao M, Brennan DM, Hacke W, Montalescot G, Steinhubl SR, Topol EJ; CHARISMA Investigators.
2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Mar 21;135(12):e686-e725. — Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FG, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RA, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME.
Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J. 2021 Oct 14;42(39):4013-4024. — Aboyans V, Bauersachs R, Mazzolai L, Brodmann M, Palomares JFR, Debus S, Collet JP, Drexel H, Espinola-Klein C, Lewis BS, Roffi M, Sibbing D, Sillesen H, Stabile E, Schlager O, De Carlo M.

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Literature

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