Treating Peripheral Arterial Disease After Revascularization - Episode 10

Current Treatment Algorithms for PAD

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Sonia Anand, MD, PhD, explains the current treatment options used in PAD therapy.

Manesh Patel, MD: Sonia, how do you see this getting put into practice? What are the pathways and the ways people are putting the therapy in your practice or what are some of the barriers? And then we can maybe wrap up with our team here thinking about what’s coming and what are the key things we see coming in the future.

Sonia Anand, MD, PhD: Thanks, Manesh. That’s a question we often get. Okay, all this great data, now who do I treat? We’ve done a lot of additional analyses from COMPASS and now VOYAGER, and we’ve really come back to that question of risk. In both trials, COMPASS and VOYAGER, we included high-risk patients. So, you would be in a good position to say I’m going to treat any patient with PAD with COMPASS or VOYAGER with this dual pathway inhibition that would be completely fine. But we do have questions that say, okay, if we don’t have unlimited resources or drug supply and we’re also always wondering about bleeding, can you make it easy for us and just tell us who we treat without too much thinking, and I would come back to those risk stratification analyses that we’ve done.

Certainly, the low-hanging fruit, the patients we should treat without too much thinking are those patients with polyvascular disease or patients with vascular disease, either CAD or PAD who have an additional high-risk feature. And that would include diabetes, a history of heart failure, or renal insufficiency. So that makes it really easy, who do I treat.

Now, we still may get questions in the PAD circles about, okay, who with PAD should I treat? If you have to, post-revascularization, infrainguinal, you’ve seen it from VOYAGER, they all will benefit with this therapy, irrespective of the surgical intervention or endovascular. We also then would see patients with severe symptoms of PAD. So, in our analysis from COMPASS, if you have severe symptoms such as rest pain or non-healing ulcers, that CLI population, they benefit. And any patient with a previous history of a revascularization due to PAD, they benefit. It leaves us with the only group where I might debate would be a patient with PAD who has mild intermittent claudication without concomitant CAD, without any of those high-risk features or comorbid conditions. Maybe in that population I’ll start with a single antiplatelet agent and wait and see.

Manesh Patel, MD: That was really helpful. Thanks, Sonia.

This transcript has been edited for clarity.