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CLINICAL STATEMENTS AND GUIDELINES June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1336 revascularization procedures and major amputation in elderly patients when compared with younger patients with PAD.14,15,20,21 Identification of these geriatric syndromes in older adults with PAD can be a catalyst for shared decision-making to evaluate the use of endovascular, surgical, or hybrid revascularization procedures to balance the risk of complications or loss of independence against the potential for improved QOL and palliation of symptoms with a limited life span. 5 MEDICAL THERAPY AND PREVENTIVE FOOT CARE FOR PATIENTS WITH PAD GDMT for PAD is implemented to reduce the risk of progression to more symptomatic and limb-threatening clinical presentations of PAD and MALE and to reduce the risk of MACE, particularly death, MI, and stroke (Figure 4). Medical therapy for PAD may also be implemented to improve leg symptoms attributable to claudication. For patients with PAD, preventive foot care is implemented to prevent the development of ulceration and the risk of CLTI. 5.1 Antiplatelet and Antithrombotic Therapy for PAD Recommendations for Antiplatelet and Antithrombotic Therapy for PAD Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 A 1 In patients with symptomatic PAD, single antiplatelet therapy is recommended to reduce the risk of MACE.1–4 1 B-R 2 In patients with symptomatic PAD, single antiplatelet therapy with clopidogrel alone (75 mg daily) is recommended to reduce the risk of MACE.4 1 C-LD 3 In patients with symptomatic PAD, single antiplatelet therapy with aspirin alone (range, 75-325 mg daily) is recommended to reduce the risk of MACE.1–3 1 A 4 In patients with symptomatic PAD, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin is effective to reduce the risk of MACE and MALE.5,6 1 B-R 5. After endovascular or surgical revascularization for PAD, antiplatelet therapy is recommended.1,7–9 1 A 6 After endovascular or surgical revascularization for PAD, low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin is recommended to reduce the risk of MACE and MALE.7 2a C-LD 7 After endovascular revascularization for PAD, dual antiplatelet therapy with a P2Y12 antagonist and low-dose aspirin is reasonable for at least 1 to 6 months.8–11 2a C-LD 8 After endovascular or surgical revascularization in patients with PAD who require full-intensity anticoagulation for another indication and are not at high risk of bleeding, adding single antiplatelet therapy is reasonable.12,13 2a C-EO 9 In patients with asymptomatic PAD, single antiplatelet therapy is reasonable to reduce the risk of MACE. 2b B-R 10. In patients with symptomatic PAD without recent revascularization, the benefit of dual antiplatelet therapy is uncertain.14,15 2b B-R 11. In patients with symptomatic PAD, the benefit of vorapaxar added to existing antiplatelet therapy is uncertain.16 2b B-R 12. After surgical revascularization for PAD with a prosthetic graft, dual antiplatelet therapy with a P2Y12 antagonist and low-dose aspirin may be reasonable for at least 1 month.17 3: Harm A 13. In patients with PAD without another indication (eg, atrial fibrillation), full-intensity oral anticoagulation should not be used to reduce the risk of MACE and MALE.18–20 Synopsis Antiplatelet and antithrombotic therapies are core components of medical therapy for patients with PAD. Aspirin or other antiplatelet drugs are used to prevent MI, ischemic stroke, and vascular death in patients with clinical atherosclerosis (eg, symptomatic PAD, CAD, or cerebrovascular disease).1,4–6 The value of these agents in asymptomatic PAD is less certain because clinical trials show a higher risk of bleeding with these regimens, which may offset any lowering of the risk of ischemic events.21,22 The use of dual antiplatelet therapy (eg, aspirin plus clopidogrel) and the use of more potent antiplatelet medications (eg, vorapaxar) in patients without recent revascularization (ie, revascularization within 6 months) is also uncertain based on higher risks of bleeding.14,15,16 Recent RCTs have shown that the low-dose direct oral anticoagulant rivaroxaban plus low-dose aspirin prevents ischemic events compared with aspirin alone but with a higher risk of major bleeding.5,6 Many patients with symptomatic PAD have had previous revascularization (either endovascular or surgical), and studies have shown that these patients are at higher residual risk of cardiovascular and limb events; however, no evidence is available to support the use of more potent antiplatelet agents or dual antiplatelet therapy outside of a recent revascularization procedure. Additionally, the use of full-intensity oral anticoagulation (in the absence of another indication, such as atrial fibrillation) is not warranted and may be harmful. In patients with PAD who have undergone revascularization procedures, antiplatelet and antithrombotic therapies have been shown to reduce the occurrence of recurrent symptoms and MALE. The decision to add a medication or continue an existing medication is dependent on multiple factors, including comorbid patient conditions such as CAD, complexity of the revascularization procedure, and overall patient risk of MACE and MALE. 7,10,11 Recommendations for Antiplatelet and Antithrombotic Therapy for PAD (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026