Abstract
Peripheral arterial disease (PAD) is a major medical/surgical problem associated with
high risk for coronary heart disease (CHD). Anticoagulation plays a significant role
in the management of the PAD patient. However, evidence-based medicine supports only
select anticoagulants, mainly antiplatelet agents. The available anticoagulant classes,
their individual medications, and the mechanisms of action are described. Dextran
40, platelet glycoprotein (GP) IIb/IIIa receptor antagonists, direct thrombin (factor
IIa, FIIa) inhibitors, and factor Xa (FXa) inhibitors do not, at this juncture, appear
to have a significant role to play in the PAD patient. Aspirin has been used in PAD
patients for a few decades, as has warfarin, but the role of warfarin is very limited.
An attempt has been made to place each medication and its function in context all
the way to the present with oral direct thrombin (FIIa) and FXa inhibitors described.
These inhibitors may ultimately play an, as yet, undefined role in PAD. Specific use
of anticoagulants in PAD patients is described and aspirin still stands out as a fundamental
therapy. The thienopyridines, especially clopidogrel, have their established place
and there is some evidence for benefit from the use of clopidogrel in dual therapy
with aspirin. Dipyridamole, especially with aspirin as dual therapy, and cilostazol
also have their evidence-based niches. The main role played by warfarin is for the
patient with a vein graft in the arterial circulation. Heparin retains significant
procedural importance. For now, Class I, Level of Evidence A center around aspirin
for the PAD patient with clopidogrel, an alternative agent.
Keywords
anticoagulation - aspirin - cardiovascular disease - coronary artery - peripheral
arterial disease - risk factors - thienopyridines
