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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1338

therapy (aspirin or P2Y12 inhibitor) in addition to oral anticoagulation.12,13 These data may be applied to support single antiplatelet therapy for patients with PAD who undergo endovascular or surgical revascularization, who are not at elevated risk of bleeding, and who have another indication for full-intensity anticoagulation (eg, atrial fibrillation, venous thromboembolism). An ACC Expert Consensus Decision Pathway on oral anticoagulation and antiplatelet therapy has been published, although it focuses primarily on evidence and clinical scenarios/medication regimens for patients undergoing percutaneous coronary intervention.13 Guidelines for management of atrial fibrillation that include recommendations for oral anticoagulation in the setting of other comorbidities, including PAD, have also been published.26

9 Patients with asymptomatic PAD may be too func-

tionally limited to allow for the development of leg symptoms. Despite a lack of reported symptoms, patients with asymptomatic PAD have been demonstrated to be at increased risk of MACE, including mortality.27,28 Several studies have attempted to address whether patients with asymptomatic PAD, defined as having an abnormal ABI with no reported leg symptoms (eg, as identified during a screening examination), derived benefit from aspirin; however, none have provided adequate evidence.2,21,22 The CLIPS (Critical Leg Ischemia Prevention) trial randomized symptomatic and asymptomatic patients with abnormal ABI or TBI (defined as <0.85 and <0.6, respectively) to aspirin or placebo but was stopped early and subsequently underpowered to assess the effect of aspirin on MACE and MALE in the subgroup of patients with asymptomatic PAD.2 Both the AAA (Aspirin for Asymptomatic Atherosclerosis) trial and the POPADAD (Prevention of Progression of Arterial Disease and Diabetes) trial used a higher ABI threshold for enrollment in the study than is considered diagnostic of asymptomatic PAD (ABI ≤0.95 and <1.00, respectively) and had a relatively high mean ABI among individuals randomized (approximately 0.86 and 0.90, respectively), limiting the generalizability of findings to the asymptomatic PAD patient population.21,22 Despite the lack of evidence specific to patients with asymptomatic PAD, single antiplatelet therapy to prevent

Figure 4. Medical Therapy and Foot Care for PAD. Colors correspond to Table 3. Afib indicates atrial fibrillation; BID, 2 times daily; CLTI, chronic limb-threatening ischemia; DAPT, dual antiplatelet therapy; PAD, peripheral artery disease; SAPT, single antiplatelet therapy; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; and VTE, venous thromboembolism.

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