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OSU Peripheral Arterial Disease (PAD) Screening Tool

Assess & Diagnosis PAD in the Outpatient Setting

Kelly Rudd, Jennifer Glen

Provided by OSU Center for Health Sciences
Play
Instructions
  • Routine ABI screening for those not at increased risk of PAD is not recommended
  • Patients at increased risk for PAD:
    • Age >64
    • Age 50-64 plus risk factors for atherosclerosis (eg, diabetes, history of smoking, dyslipidemia, hypertension), chronic kidney disease, or familyhistory of PAD
    • Age <50 plus diabetes and 1 additional risk factor for atherosclerosis
0%

Why Clinicians Ought to Consider a Screening Tool For Peripheral Arterial Disease (PAD)?

Screening for PAD is crucial for early diagnosis, reducing cardiovascular events, preventing limb loss, and improving overall patient outcomes.

 

1. Early Detection and Prevention of Severe Complications

  • PAD is often asymptomatic in its early stages but can progress to critical limb ischemia, increasing the risk of ulcers, gangrene, and amputation.
  • Early diagnosis allows for timely interventions to prevent disease progression and severe outcomes.

2. Indicator of Systemic Atherosclerosis and Cardiovascular Risk

  • PAD is a strong marker of generalized atherosclerosis and is associated with an increased risk of myocardial infarction, stroke, and cardiovascular death.
  • Screening helps identify patients at high cardiovascular risk, leading to early initiation of preventive strategies.

3. Improved Management and Treatment Outcomes

  • Early detection allows for lifestyle modifications (smoking cessation, supervised exercise therapy) and medical management (antiplatelet therapy, hyperlipidemia treatment, antihypertensives, etc.) to slow disease progression.
  • Proper management reduces symptoms such as intermittent claudication and improves mobility and quality of life.

4. Cost-Effective Prevention Strategy

  • Detecting PAD early reduces the economic burden associated with advanced disease treatment, including hospitalizations, surgical interventions, and amputations.

5. Targeted Screening for High-Risk Groups

  • Individuals with diabetes, smoking history, hypertension, hyperlipidemia, and those aged 65+ are at higher risk and benefit most from screening.

 

App Components

The OSU PAD Screening app incorporates several assessment modalities to assist the clinician in detecting the presence of PAD.

1. ABPI calculator & diagnostic recommendations

2. High risk limb presentation screen

3. Quality of Life Survey (VASCUQOL-6)

4. Antithrombotic medication management strategies for asymptomatic PAD, symptomatic PAD & PAD post revascularization (AC Forum Rapid Resources)

5. Risk factor and risk amplifying conditions screening

6. Risk reduction strategies

 

Why Include Symptom-based Assessments?

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. 

 

Why Include Medication Management Strategies?

Studies indicate medication use can decrease the rates of Major Adverse Limb Events (MALE) and/or Major Adverse Cardiovascular Events (MACE). 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 (MACE and MALE) as compared to aspirin alone. Additional factors, such as bleeding risk, also play 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 versus benefits. 

 

This app also intentionally evaluates for barriers to care, including medication access, assessment of social determinants of health, and identification of populations with known health disparities in PAD identification and treatment.

 

The medication management decision support 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."

 

App Logic

To learn how the app logic works, you can inspect the app builder or refer to the PAD App Logic Map.

All questions & possible results

Triage ITitle not visible
Does the patient have a known history of PAD?

Select one option:

  • No
  • Yes
History of revascularization or non-traumatic amputation related to peripheral arterial disease (PAD)?

Select one option:

  • No
  • Yes
Triage IITitle not visible
Currently taking oral anticoagulation medication for another condition?

Select one option:

  • No
  • Yes
Select indication for current oral anticoagulation therapy.

Atrial fibrillation (Afib)

Antiphospholipid syndrome (APS)

Venous thromboembolism (VTE treatment)

Select one option:

  • Long-term anticoagulation (e.g., Afib, 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)
Management
Select Medication Management (No PAD or non-compressible ABI)

Select all that apply:

  • No new medication indicated in the absence of clinical PAD
  • Continue current anticoagulation therapy as previously prescribed
  • Aspirin 81mg daily
Select Medication Management (PAD)

Treatment Options

If Symptomatic - Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

If Symptomatic & high bleed risk - Monotherapy

  • Aspirin 81mg daily

If Asymptomatic  - Monotherapy

  • Aspirin 81mg daily -OR- Clopidogrel 75mg daily

If Asymptomatic & high bleed risk - Monotherapy

  • Aspirin 81mg daily

 

For claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

Footnote

  • Guidance suggests continuing current anticoagulation therapy if taken for another compelling indication.  May consider adding aspirin therapy, as appropriate depending on bleeding risk.*
  • 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.

 

*Factors contributing to increased bleeding risk include: 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.

 

Select all that apply:

  • Rivaroxaban 2.5mg BID
  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Other P2Y12 inhibitor (e.g., ticagrelor)
  • Cilostazol 75mg BID (For claudication)
  • Continue current anticoagulation therapy as previously prescribed
  • Deferred
  • Discontinue current antithrombotic agent (therapy change)
Select Medication Management (PAD) - Increased Bleed Risk!

Treatment Options (Caution: High Bleed Risk Indicated!)

 

If Symptomatic - Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg BID  -PLUS-
  • Aspirin 81 mg daily

If Symptomatic & high bleed risk - Monotherapy

  • Aspirin 81mg daily

If Asymptomatic  - Monotherapy

  • Aspirin 81mg daily -OR- Clopidogrel 75mg daily

If Asymptomatic & high bleed risk - Monotherapy

  • Aspirin 81mg daily

 

For claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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 .

 

 

Select all that apply:

  • Rivaroxaban 2.5mg BID
  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Other P2Y12 inhibitor (e.g., ticagrelor)
  • Cilostazol 75mg BID (For claudication)
  • Continue current anticoagulation therapy as previously prescribed
  • Deferred
  • Discontinue current antithrombotic agent (therapy change)
Select Medication Management (<30days post revascularization)

**Consider prompt care coordination with vascular interventionalist**

**Follow-up in 30 days**

 

Treatment Options < 30 days post revascularization: (With close monitoring if Increased Bleed Risk!)

 

Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg twice daily -PLUS-
  • Aspirin 81mg daily  
  • Verify all P2Y12 prescriptions have been discontinued at pharmacy.

 

-OR-

 

Dual Antiplatelet Therapy (DAPT): 

  • Clopidogrel 75mg daily -PLUS-
  • Aspirin 81mg daily

 

For claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

Footnote

  • No literature is available to compare the efficacy and safety of DPI and DAPT in this population. DPI has been shown to reduce the risk of MACE and MALE following endovascular or surgical intervention (HR 0.85, p = 0.009, VOYAGER-PAD trial). No increase in fatal bleeding or intracranial bleeding was seen. ISTH major bleeding occurred in 5.94% in DPI (vs. 4.06% aspirin alone; hazard ratio, 1.42; 95% CI, 1.10 to 1.84; P=0.007). 
  • Rates of DAPT therapy have been extrapolated from percutaneous coronary interventions, with published major bleeding rates of 3.1-6.2% (ACC 2020, CHARISMA Trial.) 
  • View the full Anticoagulation Forum ACE Rapid Resource decision tree on PAD and DPI. 

 

Select all that apply:

  • Rivaroxaban 2.5mg BID
  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Other P2Y12 inhibitor (e.g., ticagrelor)
  • Cilostazol 75mg BID (For claudication)
  • Continue current anticoagulation therapy as previously prescribed
  • Deferred
  • Discontinue current antithrombotic agent (therapy change)
Select Medication Management (<30days post revascularization) - Increased Bleed Risk!

**Consider prompt care coordination with vascular interventionalist**

**Follow-up in 30 days**

 

Treatment Options < 30 days post revascularization: (With close monitoring - Increased Bleed Risk!)

 

Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg twice daily -PLUS-
  • Aspirin 81mg daily  
  • Verify all P2Y12 prescriptions have been discontinued at pharmacy.

 

-OR-

 

Dual Antiplatelet Therapy (DAPT): 

  • Clopidogrel 75mg daily -PLUS-
  • Aspirin 81mg daily

 

For claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

Footnote

  • No literature is available to compare the efficacy and safety of DPI and DAPT in this population. DPI has been shown to reduce the risk of MACE and MALE following endovascular or surgical intervention (HR 0.85, p = 0.009, VOYAGER-PAD trial). No increase in fatal bleeding or intracranial bleeding was seen. ISTH major bleeding occurred in 5.94% in DPI (vs. 4.06% aspirin alone; hazard ratio, 1.42; 95% CI, 1.10 to 1.84; P=0.007). 
  • Rates of DAPT therapy have been extrapolated from percutaneous coronary interventions, with published major bleeding rates of 3.1-6.2% (ACC 2020, CHARISMA Trial.) 
  • View the full Anticoagulation Forum ACE Rapid Resource decision tree on PAD and DPI. 

 

 

 

 

Select all that apply:

  • Rivaroxaban 2.5mg BID
  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Other P2Y12 inhibitor (e.g., ticagrelor)
  • Cilostazol 75mg BID (For claudication)*
  • Continue current anticoagulation therapy as previously prescribed
  • Deferred
  • Discontinue current antithrombotic agent (therapy change)
Select Medication Management (>6 months post revascularization history)

Treatment Options (Review bleeding risk from previous assessment)

 

PAD: Dual Pathway Inhibition (DPI) 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

 

PAD & Increased Bleed Risk: Consider Monotherapy

  • Aspirin 81mg daily

 

PAD & on antithrombotic therapy for alternate indication:

  • Continue current antithrombotic strategy -PLUS-
  • ADD Aspirin 81 mg daily if bleeding risk allows.

 

For claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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 .

 

Select all that apply:

  • Rivaroxaban 2.5mg BID
  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Other P2Y12 inhibitor (e.g., ticagrelor)
  • Cilostazol 75mg BID (For claudication)*
  • Continue current anticoagulation therapy as previously prescribed
  • Deferred
  • Discontinue current antithrombotic agent (therapy change)
Select Medication Management (>6 months post revascularization history) - Increased Bleed Risk!

Treatment Options (Review bleeding risk from previous assessment) -Bleed Risk!

 

PAD: Dual Pathway Inhibition (DPI) 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

 

PAD & Increased Bleed Risk: Consider Monotherapy

  • Aspirin 81mg daily

 

PAD & on antithrombotic therapy for alternate indication:

  • Continue current antithrombotic strategy -PLUS- 
  • ADD Aspirin 81 mg daily if bleeding risk allows.

 

For claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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 .

 

Select all that apply:

  • Rivaroxaban 2.5mg BID
  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Other P2Y12 inhibitor (e.g., ticagrelor)
  • Cilostazol 75mg BID (For claudication)*
  • Continue current anticoagulation therapy as previously prescribed
  • Deferred
  • Discontinue current antithrombotic agent (therapy change)
Select Medication Management (1-6 months post revascularization history)

**Consider prompt care coordination with vascular interventionalist**

 

Treatment Options (With close monitoring if Increased Bleed Risk!)

 

Dual Pathway Inhibition (DPI) 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily
  • Verify all P2Y12 prescriptions have been discontinued at pharmacy

 

-OR-

 

Alternative - Dual Antiplatelet Therapy (DAPT) 

  • Clopidogrel 75mg daily -PLUS-
  • Aspirin 81mg daily

 

For claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

Footnote

  • No literature is available to compare the efficacy and safety of DPI and DAPT in this population. DPI has been shown to reduce the risk of MACE and MALE following endovascular or surgical intervention (HR 0.85, p = 0.009, VOYAGER-PAD trial). No increase in fatal bleeding or intracranial bleeding was seen. ISTH major bleeding occurred in 5.94% in DPI (vs. 4.06% aspirin alone; hazard ratio, 1.42; 95% CI, 1.10 to 1.84; P=0.007). 
  • Rates of DAPT therapy have been extrapolated from percutaneous coronary interventions, with published major bleeding rates of 3.1-6.2% (ACC 2020, CHARISMA Trial.) 
  • View the full Anticoagulation Forum ACE Rapid Resource decision tree on PAD and DPI. 

 

 

Select all that apply:

  • Rivaroxaban 2.5mg BID
  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Other P2Y12 inhibitor (e.g., ticagrelor)
  • Cilostazol 75mg BID (For claudication)*
  • Continue current anticoagulation therapy as previously prescribed
  • Deferred
  • Discontinue current antithrombotic agent (therapy change)
Select Medication Management (1-6 months post revascularization history) - Increased Bleed Risk!

**Consider prompt care coordination with vascular interventionalist**

 

Treatment Options (With close monitoring - Increased Bleed Risk!)

 

Dual Pathway Inhibition (DPI) 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily
  • Verify all P2Y12 prescriptions have been discontinued at pharmacy

 

-OR-

 

Alternative - Dual Antiplatelet Therapy (DAPT) 

  • Clopidogrel 75mg daily -PLUS-
  • Aspirin 81mg daily

 

For claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

Footnote

  • No literature is available to compare the efficacy and safety of DPI and DAPT in this population. DPI has been shown to reduce the risk of MACE and MALE following endovascular or surgical intervention (HR 0.85, p = 0.009, VOYAGER-PAD trial). No increase in fatal bleeding or intracranial bleeding was seen. ISTH major bleeding occurred in 5.94% in DPI (vs. 4.06% aspirin alone; hazard ratio, 1.42; 95% CI, 1.10 to 1.84; P=0.007). 
  • Rates of DAPT therapy have been extrapolated from percutaneous coronary interventions, with published major bleeding rates of 3.1-6.2% (ACC 2020, CHARISMA Trial.) 
  • View the full Anticoagulation Forum ACE Rapid Resource decision tree on PAD and DPI. 

 

 

Select all that apply:

  • Rivaroxaban 2.5mg BID
  • Aspirin 81mg daily
  • Clopidogrel 75mg daily
  • Other P2Y12 inhibitor (e.g., ticagrelor)
  • Cilostazol 75mg BID (For claudication)*
  • Continue current anticoagulation therapy as previously prescribed
  • Deferred
  • Discontinue current antithrombotic agent (therapy change)
Select Applicable Risk-amplifying Comorbidities
Age >75 years or geriatric syndrome?
  • Geriatric Syndrome: The presence of geriatric syndromes (i.e. frailty, mobility impairment, cognitive decline, sarcopenia, malnutrition, cognitive decline, etc.) are considered PAD risk amplifiers, as they may obscure the symptoms of PAD.

Select one option:

  • No
  • Yes
Current tobacco use?

Select one option:

  • No (Never Tobacco User)
  • No (Former Tobacco User)
  • Yes - Cessation Offered
  • Yes - Cessation Initiated
Diabetes?

Select one option:

  • No
  • Yes - At A1c goal
  • Yes - Not at A1c goal
Chronic or end-stage kidney disease (eGFR <60ml/min)?

Select one option:

  • No
  • Yes - Treatment optimized
  • Yes - Care optimizations possible
Polyvascular disease (2-bed vascular disease or more)?
  • Polyvascular Disease: The concurrent presence of peripheral, cardiac, or cerebrovascular atherosclerotic manifestations is referred to as polyvascular disease, to include a history of MI, CVA, TIA, heart failure, prior surgery on blood vessels and ischemic limb events.

Select one option:

  • No
  • Yes - Treatment optimized
  • Yes - Care optimizations possible
Microvascular disease?
  • Microvascular Disease: Abnormalities in the microvasculature, often leading to, and manifesting as, retinopathy, neuropathy, nephropathy, arthritis, back, knee or nerve pain, etc.

Select one option:

  • No
  • Yes - Treatment optimized
  • Yes - Care optimizations possible
Depression?

Select one option:

  • No
  • Yes - Treatment optimized
  • Yes - Care optimizations possible
Identification of Risk-amplifiers
Race: Black or African American, Hispanic or Latino, American Indian or Alaska Native?

Select one option:

  • No
  • Yes
Hypertension?

Select one option:

  • No
  • Yes - At goal (Guideline Goal: Blood pressure <130/80)
  • Yes - Care optimizations possible
Hyperlipidemia?

Select one option:

  • No
  • Yes - At goal (Guideline Goal: LDL <70mg/dL)
  • Yes - Care optimizations possible
Current signs of necrosis or gangrene of limb?

Select one option:

  • No
  • Yes
Risk Reduction Strategies
Select all that apply

Select all that apply:

  • Cardiovascular disease risk reduction strategies (e.g., diet, exercise, etc.)
  • Evaluation for barriers to care and/or health disparities
  • Optimize comorbidity management
  • Preventative foot care
  • Referral to Vascular Specialist
  • Structured exercise program
  • Update vaccinations as needed (e.g., influenza, coronavirus, RSV, pneumonia, etc.)
  • Deferred
Measuring the ABI

Watch a YouTube video on How to Measure the Ankle Brachial Index

 

Which brachial blood pressures?

Select all that apply:

  • RIGHT brachial
  • LEFT brachial
RIGHT brachial systolic pressure

A number between 0 and 300 (whole numbers), in mmHg.

LEFT brachial systolic pressure

A number between 0 and 300 (whole numbers), in mmHg.

Which RIGHT ankle blood pressures?

Select all that apply:

  • dorsalis pedis (DP)
  • posterior tibial (PT)
RIGHT ankle/dorsalis pedis (DP) systolic pressure

A number between 0 and 300 (whole numbers), in mmHg.

RIGHT ankle/posterior tibial (PT) systolic pressure

A number between 0 and 300 (whole numbers), in mmHg.

Which LEFT ankle blood pressures?

Select all that apply:

  • dorsalis pedis (DP)
  • posterior tibial (PT)
LEFT ankle/dorsalis pedis (DP) systolic pressure

A number between 0 and 300 (whole numbers), in mmHg.

LEFT ankle/posterior tibial (PT) systolic pressure

A number between 0 and 300 (whole numbers), in mmHg.

TriageTitle not visible
Currently taking oral anticoagulation medication for another condition?

Select one option:

  • No
  • Yes
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:

  • No
  • Yes
TriageTitle not visible
Length of time since amputation or revascularization?

Select one option:

  • < 30 days
  • 1-6 months
  • > 6 months
Part I: DPI Algorithm in PAD With History of Revascularization or Symptomatic PADTitle not visible
Is the patient already on short-term anticoagulation (e.g., VTE initial treatment)?

Select one option:

  • No
  • Yes (Patient may NOT be a candidate for Dual Pathway Inhibition (DPI) with rivaroxaban PLUS aspirin at this time.)
Is the patient already on long-term anticoagulation for AF, mechanical valve, antiphospholipid syndrome (APS), or extended venous thromboembolism (VTE) treatment?

Select one option:

  • No
  • Yes (Current use of oral anticoagulants for another condition may be a contraindication for DPI or DAPT in the treatment of PAD)
Is the patient already taking dual antiplatelet therapy for that is required for > 1 month?

*e.g., acute coronary syndrome, recent DES placement inn coronary or below knee arteries

Select one option:

  • No
  • Yes (Patient may NOT be a candidate for a change to DPI at this time. Further assessment required.)
Part II: DPI Algorithm in PAD With History of Revascularization or Symptomatic PADTitle not visible
Is CrCl < 15 ml/min?

Select one option:

  • No
  • Yes (CrCl <15 ml/min is a contraindication for Rivaroxaban)
Allergy to aspirin?

Select one option:

  • No
  • Yes (ASA allergy is a contraindication for DPI or DAPT. Consider clopidogrel monotherapy as an alternative.)
Is the patient already prescribed or using aspirin?

Select one option:

  • No
  • Yes
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 DPI or DAPT)
Is Rivaroxaban cost or lack of insurance a barrier?

Select one option:

  • No
  • Yes
Is the patient already taking other medication that is contraindicated for use with rivaroxaban?

Contraindication Examples

  • Combined CYP3a and P-gp inducers and inhibitors (ketoconazole, ritonavir, erythromycin, carbamazepine, phenytoin, rifampin, St. John’s wort, etc.) - Xarelto Package Insert. Janssen Pharmaceuticals, 2023.

Select one option:

  • No
  • Yes
Does the person have any of the following symptoms?
Loss of feeling or tingling in the legs or feet?

Select one option:

  • Never
  • Sometimes
  • Often
  • Always
Toes that are pale, discolored or bluish?

Select one option:

  • Never
  • Sometimes
  • Often
  • Always
Feet that are cold to the touch or one foot that is colder than the other?

Select one option:

  • Never
  • Sometimes
  • Often
  • Always
Sores, wounds or ulcers on the legs or feet?

Select one option:

  • Never
  • Sometimes
  • Often
  • Always
Leg pain that disturbs your sleep or pain at rest?

Select one option:

  • Never
  • Sometimes
  • Often
  • Always
Aching, cramping or pain in your legs, calves, buttocks or thighs when you walk or exercise?

Select one option:

  • Never
  • Sometimes
  • Often
  • Always
DefaultTitle not visible
Does the aching, cramping or pain in your legs, calves, buttocks or thighs when you walk or exercise persist even at rest?

Select one option:

  • Never
  • Sometimes
  • Often
  • Always
Does the person have heart failure or cardiomyopathy?

Select one option:

  • No
  • Yes
Part I: DPI Algorithm in PAD With History of Revascularization or Symptomatic PADTitle not visible
Is the patient already on short-term anticoagulation (e.g., VTE initial treatment)?

Select one option:

  • No
  • Yes (Patient may NOT be a candidate for Dual Pathway Inhibition (DPI) with rivaroxaban PLUS aspirin at this time.)
Is the patient already on long-term anticoagulation for AF, mechanical valve, antiphospholipid syndrome (APS), or extended venous thromboembolism (VTE) treatment?

Select one option:

  • No
  • Yes (Current use of oral anticoagulants for another condition may be a contraindication for DPI or DAPT in the treatment of PAD)
Is the patient already taking dual antiplatelet therapy for that is required for > 1 month?

*e.g., acute coronary syndrome, recent DES placement inn coronary or below knee arteries

Select one option:

  • No
  • Yes (Patient may NOT be a candidate for a change to DPI at this time. Further assessment required.)
Part II: DPI Algorithm in PAD With History of Revascularization or Symptomatic PADTitle not visible
Is CrCl < 15 ml/min?

Select one option:

  • No
  • Yes (CrCl <15 ml/min is a contraindication for Rivaroxaban)
Allergy to aspirin?

Select one option:

  • No
  • Yes (ASA allergy is a contraindication for DPI or DAPT. Consider clopidogrel monotherapy as an alternative.)
Is the patient already prescribed or using aspirin?

Select one option:

  • No
  • Yes
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 DPI or DAPT)
Is Rivaroxaban cost or lack of insurance a barrier?

Select one option:

  • No
  • Yes
Is the patient already taking other medication that is contraindicated for use with rivaroxaban?

Contraindication Examples

  • Combined CYP3a and P-gp inducers and inhibitors (ketoconazole, ritonavir, erythromycin, carbamazepine, phenytoin, rifampin, St. John’s wort, etc.) - Xarelto Package Insert. Janssen Pharmaceuticals, 2023.

Select one option:

  • No
  • Yes
Default SectionTitle not visible
Because of the poor circulation in my legs, the range of activities that I would have liked to do in the past two weeks has been....

Select one option:

  • Severely limited – most activities not done
  • Moderately limited – several activities not done
  • Very slightly limited – very few activities not done
  • Not limited at all – have done all the activities that I wanted to
During the past two weeks, my legs felt tired or weak....

Select one option:

  • All of the time
  • Some of the time
  • A little of the time
  • None of the time
During the past two weeks, because of the poor circulation in my legs, my ability to walk has been....

Select one option:

  • Totally limited, couldn’t walk at all
  • Very limited
  • A little limited
  • Not at all limited
During the past two weeks, I have been concerned about having poor circulation in my legs....

Select one option:

  • All of the time
  • Some of the time
  • A little of the time
  • None of the time
During the past two weeks, because of the poor circulation in my legs, my ability to participate in social activities has been....

Select one option:

  • Totally limited, couldn’t socialize at all
  • Very limited
  • A little limited
  • Not at all limited
During the past two weeks, when I have had pain in the leg (or foot) it has given me...

Select one option:

  • A great deal of discomfort or distress
  • A moderate amount of discomfort or distress
  • Very little discomfort or distress
  • No discomfort or distress
Possible results
Chronic or End-stage Kidney Disease - Potential for therapy optimization (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
No PAD Plus Other Indication for AC
Diabetes - Not at goal (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
  • Treatment per guideline directed therapy (2024 Standards of Care in Diabetes by the American Diabetes Association)
  • GLP-1 agonists & SGLT-2 inhibitors reduce the risk of MACE
Current Tobacco Use - Cessation Offered (Risk Amplifying Comorbidity)
History of Hypertension - Potential for therapy optimization (Risk Amplifier)

Consider:

  • Guideline Goal: Blood pressure <130/80
  • If not at goal, refer to primary care provider.
Microvascular Disease - Therapy optimized (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
History of Hyperlipidemia - Potential for therapy optimization (Risk Amplifying)

Consider:

  • Guideline Goal: LDL <70mg/dL
  • If not at goal, refer to primary care provider.
     
Microvascular Disease - Potential for therapy optimization (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
Diabetes - At goal (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
  • Treatment per guideline directed therapy (2024 Standards of Care in Diabetes by the American Diabetes Association)
  • GLP-1 agonists & SGLT-2 inhibitors reduce the risk of MACE
Current Tobacco Use - Cessation Initiated (Risk Amplifying Comorbidity)
History of Hyperlipidemia - At goal (Risk Amplifying)

Consider:

  • Guideline Goal: LDL <70mg/dL
     
Claudication
No PAD
Number of Risk-amplifying Comorbidities

Potential risk-amplifying comorbidities (see patient assessment):

  • Age >75 years or geriatric syndrome
  • Current tobacco use
  • Diabetes
  • Chronic or end-stage kidney disease (eGFR <60ml/min)
  • Polyvascular disease (2-bed vascular disease or more)
  • Microvascular disease
  • Depression
Polyvascular Disease - Potential for therapy optimization (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
Polyvascular Disease - Therapy optimized (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
PAD with Symptoms
Depression - Therapy Optimized (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
Depression - Potential for therapy optimization (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
Chronic or End-stage Kidney Disease - Therapy optimized (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for initiation or optimization
PAD Plus Other Indication for AC
History of Hypertension - At Goal (Risk Amplifier)

Consider:

  • Guideline Goal: Blood pressure <130/80
  • If not at goal, refer to primary care provider.
Asymptomatic PAD
Age >75 years or Geriatric Syndrome (Risk Amplifying Comorbidity)

Consider:

  • Referral to primary care or specialist for evaluation or therapy optimization
PAD Post Revascularization
Race (Risk Amplifier)

Consider:

  • Assessing the risk of health disparities and under-treatment, which is a national healthcare priority.
     
High Risk Limb Presentation

One or more of the following risk factors are present (see patient assessment):

  • Limb pain or numbness at rest
  • Previous amputation or revascularization
  • Necrosis or gangrene of limb
  • ABI <0.8
RIGHT Leg ABPI: Severe PAD
RIGHT Leg ABPI: Mild PAD
RIGHT Leg ABPI: No PAD
RIGHT Leg ABPI: Moderate PAD
RIGHT Leg ABPI: Borderline PAD
RIGHT Leg ABPI: Non-compressible
Left Leg ABPI: No PAD
Left Leg ABPI: Borderline PAD
Left Leg ABPI: Non-compressible
Left Leg ABPI: Moderate PAD
Left Leg ABPI: Mild PAD
Left Leg ABPI: Severe PAD
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.
1-6 months post PAD related procedure: Consider DPI or DAPT in coordination with vascular interventionalist.

**Consider prompt care coordination with vascular interventionalist**

 

Treatment Options (With close monitoring if Increased Bleed Risk!)

 

Dual Pathway Inhibition (DPI) 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily
  • Verify all P2Y12 prescriptions have been discontinued at pharmacy

 

-OR-

 

Alternative - Dual Antiplatelet Therapy (DAPT) 

  • Clopidogrel 75mg daily -PLUS-
  • Aspirin 81mg daily

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

Footnote

  • No literature is available to compare the efficacy and safety of DPI and DAPT in this population. DPI has been shown to reduce the risk of MACE and MALE following endovascular or surgical intervention (HR 0.85, p = 0.009, VOYAGER-PAD trial). No increase in fatal bleeding or intracranial bleeding was seen. ISTH major bleeding occurred in 5.94% in DPI (vs. 4.06% aspirin alone; hazard ratio, 1.42; 95% CI, 1.10 to 1.84; P=0.007). 
  • Rates of DAPT therapy have been extrapolated from percutaneous coronary interventions, with published major bleeding rates of 3.1-6.2% (ACC 2020, CHARISMA Trial.) 
  • View the full Anticoagulation Forum ACE Rapid Resource decision tree on the use of DPI.
Increased Bleeding Risk & 1-6 months post PAD related procedure: Consider DPI or DAPT in coordination with vascular interventionalist.

**Consider prompt care coordination with vascular interventionalist**

 

Treatment Options (With close monitoring - Increased Bleed Risk!)

 

Dual Pathway Inhibition (DPI) 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily
  • Verify all P2Y12 prescriptions have been discontinued at pharmacy

 

-OR-

 

Alternative - Dual Antiplatelet Therapy (DAPT) 

  • Clopidogrel 75mg daily -PLUS-
  • Aspirin 81mg daily

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

Footnote

  • No literature is available to compare the efficacy and safety of DPI and DAPT in this population. DPI has been shown to reduce the risk of MACE and MALE following endovascular or surgical intervention (HR 0.85, p = 0.009, VOYAGER-PAD trial). No increase in fatal bleeding or intracranial bleeding was seen. ISTH major bleeding occurred in 5.94% in DPI (vs. 4.06% aspirin alone; hazard ratio, 1.42; 95% CI, 1.10 to 1.84; P=0.007). 
  • Rates of DAPT therapy have been extrapolated from percutaneous coronary interventions, with published major bleeding rates of 3.1-6.2% (ACC 2020, CHARISMA Trial.) 
  • View the full Anticoagulation Forum ACE Rapid Resource decision tree on the use of DPI.
Warning: May NOT be a candidate for Dual Pathway Inhibition (DPI) with Rivaroxaban PLUS aspirin at this time

Possible reasons that may disqualify DPI as a safe treatment option:

  • CrCl < 15ml/min
  • Aspirin allergy
  • High risk of bleeding
  • Medication cost or lack of insurance coverage: Consider consult with Pharmacy or Social Work for assistance.
  • Taking other medication that is contraindicated for use with rivaroxaban

 

View the full ACE Rapid Resource decision tree.

 

Dual Pathway Inhibition (DPI): 

  • Rivaroxaban: A factor Xa inhibitor which blocks platelet activation by inhibition of thrombin formation. 
  • Aspirin: ACOX-1 inhibitor which blocks platelet activation via TXA-2 - PLUS
  • The rationale behind dual pathway inhibition is to block two different mechanisms for platelet activation to further reduce thrombotic risk
< 30 Days Post Revasc: Initiate Dual Pathway Inhibition (DPI) with Rivaroxaban 2.5mg BID PLUS aspirin 81mg daily. Follow-up in 30 days with interventionalist/surgeon.

**Consider prompt care coordination with vascular interventionalist**

**Follow-up in 30 days**

 

Treatment Options < 30 days post revascularization: (With close monitoring if Increased Bleed Risk!)

 

Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg twice daily -PLUS-
  • Aspirin 81mg daily  
  • Verify all P2Y12 prescriptions have been discontinued at pharmacy.

 

-OR-

 

Dual Antiplatelet Therapy (DAPT): 

  • Clopidogrel 75mg daily -PLUS-
  • Aspirin 81mg daily
  • Verify all P2Y12 prescriptions have been discontinued at pharmacy.

 

For Claudication symptoms:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

Footnote

  • No literature is available to compare the efficacy and safety of DPI and DAPT in this population. DPI has been shown to reduce the risk of MACE and MALE following endovascular or surgical intervention (HR 0.85, p = 0.009, VOYAGER-PAD trial). No increase in fatal bleeding or intracranial bleeding was seen. ISTH major bleeding occurred in 5.94% in DPI (vs. 4.06% aspirin alone; hazard ratio, 1.42; 95% CI, 1.10 to 1.84; P=0.007). 
  • Rates of DAPT therapy have been extrapolated from percutaneous coronary interventions, with published major bleeding rates of 3.1-6.2% (ACC 2020, CHARISMA Trial.) 
  • View the full Anticoagulation Forum ACE Rapid Resource decision tree on the use of DPI.
Warning - Aspirin Allergy & Bleed Risk! Consult a pharmacist or interventionalist for assistance.
PAD & on antithrombotic therapy for alternate indication: Continue current antithrombotic strategy -PLUS- ADD Aspirin 81 mg daily if bleeding risk allows

PAD & on antithrombotic therapy for alternate indication:

  • Continue current antithrombotic strategy -PLUS- 
  • ADD Aspirin 81 mg daily if bleeding risk allows.

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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.
Continue Dual Antiplatelet Therapy (DAPT) with P2Y12 inhibitor (e.g., clopidogrel, ticagrelor, etc.) PLUS aspirin. Revisit Dual Pathway Inhibition (DPI) in 3-6 months.

PAD & on antithrombotic therapy for alternate indication:

  • Continue current antithrombotic strategy -PLUS- 
  • ADD Aspirin 81 mg daily if bleeding risk allows.

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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.

 

Dual Antiplatelet Therapy (DAPT): 

  • P2Y12 inhibitor: (e.g., clopidogrel, ticagrelor, etc.) - PLUS 
  • Aspirin: ACOX-1 inhibitor which blocks platelet activation via TXA-2

Dual Pathway Inhibition (DPI): 

  • Rivaroxaban: A factor Xa inhibitor which blocks platelet activation by inhibition of thrombin formation. 
  • Aspirin: ACOX-1 inhibitor which blocks platelet activation via TXA-2 - PLUS
  • The rationale behind dual pathway inhibition is to block two different mechanisms for platelet activation to further reduce thrombotic risk
Increased Bleeding Risk & > 6 months post PAD related procedure: If no aspirin allergy, consider ASA 81mg PO Daily

Treatment Options (Review bleeding risk from previous assessment) -Bleed Risk!

 

PAD: Dual Pathway Inhibition (DPI) 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

 

PAD & Increased Bleed Risk: Consider Monotherapy

  • Aspirin 81mg daily

 

PAD & on antithrombotic therapy for alternate indication:

  • Continue current antithrombotic strategy -PLUS- 
  • ADD Aspirin 81 mg daily if bleeding risk allows.

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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.
> 6 months post PAD related procedure: Consider DPI

Treatment Options (Review bleeding risk from previous assessment)

 

PAD: Dual Pathway Inhibition (DPI) 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

 

PAD & Increased Bleed Risk: Consider Monotherapy

  • Aspirin 81mg daily

 

PAD & on antithrombotic therapy for alternate indication:

  • Continue current antithrombotic strategy -PLUS-
  • ADD Aspirin 81 mg daily if bleeding risk allows.

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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 .
If already taking aspirin, confirm the appropriate dosage of aspirin
Warning: May NOT be a candidate for Dual Antiplatelet Therapy (DAPT) with P2Y12 inhibitor (e.g., clopidogrel) PLUS aspirin. Aspirin Allergy!

Aspirin allergy! Consider consultation with interventionalist for treatment options.

 

Dual Antiplatelet Therapy (DAPT): 

  • P2Y12 inhibitor: (e.g., clopidogrel, ticagrelor, etc.) - PLUS 
  • Aspirin: ACOX-1 inhibitor which blocks platelet activation via TXA-2
NOT be a candidate for Dual Pathway Inhibition (DPI) with Rivaroxaban PLUS aspirin at this time - Reconsider in 1-6 months.

Possible reasons that may disqualify DPI as a safe treatment option:

  • CrCl < 15ml/min
  • Aspirin allergy
  • Medication cost or lack of insurance coverage: Consider consult with Pharmacy or Social Work for assistance.
  • High risk of bleeding
  • On long-term anticoagulation for Afib, mechanical valve, APS, or extended VTE treatment
  • On short-term anticoagulation (e.g., VTE initial treatment)
  • Taking other medication that is contraindicated for use with rivaroxaban

 

PAD & on antithrombotic therapy for alternate indication:

  • Continue current antithrombotic strategy -PLUS- 
  • ADD Aspirin 81 mg daily if bleeding risk allows.

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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.

 

Dual Pathway Inhibition (DPI): 

  • Rivaroxaban: A factor Xa inhibitor which blocks platelet activation by inhibition of thrombin formation. 
  • Aspirin: ACOX-1 inhibitor which blocks platelet activation via TXA-2 - PLUS
  • The rationale behind dual pathway inhibition is to block two different mechanisms for platelet activation to further reduce thrombotic risk
Warning - Aspirin Allergy: Consider clopidogrel 75mg PO Daily
Asymptomatic (Lack active symptoms suggestive of PAD)

Peripheral artery disease (PAD) is a common cardiovascular disease associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life (QOL), walking performance, and functional status. Detection of PAD in most patients is accomplished through the history, physical examination, and resting ankle-brachial index. Refer to the “2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease” for more guidance on the diagnosis and management of PAD.

Claudication present along with a history of heart failure or cardiomyopathy

Note: Cilostazol used for the treatment of claudication in peripheral arterial disease (PAD) is contraindicated in heart failure and cardiomyopathy

Claudication present & no history of heart failure or cardiomyopathy: May benefit from Cilostazol 75mg PO twice daily when a diagnosis of PAD is established.

An individual with claudication and a diagnosis of peripheral arterial disease (PAD) may benefit from Cilostazol 75mg PO twice daily.
 

Note: Cilostazol is contraindicated in heart failure and cardiomyopathy

Symptoms suggestive of PAD (A high value indicates higher severity)

Peripheral artery disease (PAD) is a common cardiovascular disease associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life (QOL), walking performance, and functional status. Detection of PAD in most patients is accomplished through the history, physical examination, and resting ankle-brachial index. Refer to the “2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease” for more guidance on the diagnosis and management of PAD.

Symptomatic PAD: Consider DPI. If bleed risk, consider aspirin daily only

Treatment Options

If Symptomatic - Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

If Symptomatic & high bleed risk - Monotherapy

  • Aspirin 81mg daily

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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.
CrCl < 15 ml/min: May NOT be a candidate for Dual Pathway Inhibition (DPI) with Rivaroxaban PLUS aspirin at this time (Symptomatic PAD)

Possible reasons selected that may disqualify DPI as a safe treatment option:

  • CrCl < 15ml/min
  • Medication cost or lack of insurance coverage: Consider consult with Pharmacy or Social Work for assistance.
  • Taking other medication that is contraindicated for use with rivaroxaban

 

Treatment Options

If Symptomatic - Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

If Symptomatic & high bleed risk - Monotherapy

  • Aspirin 81mg daily

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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.
Symptomatic PAD & Bleed Risk! Consider aspirin daily as monotherapy. May NOT be a candidate for DPI as this time.

Treatment Options

If Symptomatic - Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

If Symptomatic & high bleed risk - Monotherapy

  • Aspirin 81mg daily

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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.
If already taking aspirin, confirm the appropriate dosage of aspirin
Medication cost or contraindication: May NOT be a candidate for Dual Pathway Inhibition (DPI) with Rivaroxaban PLUS aspirin at this time (Symptomatic PAD)

Possible reasons selected that may disqualify DPI as a safe treatment option:

  • CrCl < 15ml/min
  • Medication cost or lack of insurance coverage: Consider consult with Pharmacy or Social Work for assistance.
  • Taking other medication that is contraindicated for use with rivaroxaban

 

Treatment Options

If Symptomatic - Dual Pathway Inhibition (DPI): 

  • Rivaroxaban 2.5mg BID -PLUS-
  • Aspirin 81 mg daily

If Symptomatic & high bleed risk - Monotherapy

  • Aspirin 81mg daily

 

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.

 

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.
Warning - Aspirin Allergy: Consider clopidogrel 75mg PO Daily
Symptomatic PAD Plus Other Indication for Short-term Anticoagulation: Continue current antithrombotic therapy as prescribed. Revisit Dual Pathway Inhibition (DPI) - Reconsider in 1-6 months

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.
Symptomatic PAD Plus Other Indication for Anticoagulation: Continue Dual Antiplatelet Therapy (DAPT) with P2Y12 inhibitor (e.g., clopidogrel, ticagrelor, etc.) PLUS aspirin. Revisit Dual Pathway Inhibition (DPI) in 3-6 months.

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.
Warning - Aspirin Allergy & Bleed Risk! Consult a pharmacist or interventionalist for assistance.
Symptomatic PAD Plus Other Indication for Long-term Anticoagulation: Continue current antithrombotic therapy as prescribed.

For claudication symptoms consider:

  • Cilostazol 75mg BID: Do NOT use in the presence of heart failure or cardiomyopathy.
VascuQol-6 Score: A higher value indicates better health status

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