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Oral Anticoagulation for Patients with Peripheral Arterial Disease?

Adding an anticoagulant to antiplatelet therapy caused more bleeding and was no more effective than antiplatelet therapy alone.

Because peripheral arterial disease (PAD) is associated with widespread vascular disease (including myocardial infarction and stroke), most patients with PAD receive antiplatelet therapies. This multinational randomized trial examined whether the combination of an antiplatelet plus oral anticoagulant is superior to an antiplatelet agent alone.

The study included 2161 patients with PAD of the legs (82%), subclavian artery, or carotid artery; half the patients also had a history of coronary disease. Patients received either an antiplatelet drug alone (mostly aspirin) or an antiplatelet drug plus oral anticoagulant (mostly warfarin). During an average follow-up of 3 years, several primary outcomes — which included combinations of cardiovascular death, MI, stroke, and arterial ischemia — did not differ significantly in the two groups. However, life-threatening or moderate bleeding occurred significantly more often with combined therapy than with antiplatelet therapy (6.9% vs. 2.2%).

Comment: In this trial, combined antiplatelet-anticoagulant therapy caused more bleeding and was no more effective than antiplatelet therapy alone in patients with peripheral arterial disease. In current practice, warfarin is generally not given to patients with PAD who have no other indications for oral anticoagulants; this study confirms the wisdom of that approach. However, patients with PAD sometimes receive warfarin for other reasons and are continued on that drug even after the non-PAD indication disappears; this study strongly suggests that such patients would be better off taking aspirin alone.

— Allan S. Brett, MD

Published in Journal Watch General Medicine July 18, 2007

Citation(s):

The Warfarin Antiplatelet Vascular Evaluation Trial Investigators. Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. N Engl J Med 2007 Jul 19; 357:217-27.

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