title: Adverse cardiovascular outcomes in relation to suboptimal antithrombotic therapy use in patients undergoing peripheral artery disease angioplasty: lost opportunities?
abstract: BACKGROUND
  Current guidelines recommend antithrombotic therapy with either aspirin or clopidogrel for all patients with peripheral arterial disease (PAD). Nevertheless, cardiovascular comorbidities and perceived bleeding risk complicate antithrombotic management of PAD patients. We studied the proportion of patients receiving optimal (guideline-recommended) antithrombotic therapy, and second, assessed the impact of suboptimal antithrombotic therapy use to long-term outcomes of PAD patients.
  
  
  METHODS
  We performed a single centre retrospective analysis of patients with significant PAD, requiring percutaneous intervention. All patients coded as undergoing peripheral artery percutaneous transluminal angioplasty (PTA) between January 2007 and December 2011 were reviewed. Antithrombotic medication on discharge postprocedure was recorded.
  
  
  RESULTS
  Across the study period, 473 patients were coded as having received a PTA, but yet only 336 (71%) had data available for review: 218 (35.2%) male, mean age 73 ± 11 years. Of the whole cohort, 236 (70.2%) were discharged on optimal (guideline-recommended) antithrombotic therapy, 30 (8.9%) were considered 'overtreated' and 70 (20.8%) were undertreated. On multivariate analysis, patients with heart failure were more likely to be undertreated (OR 2.38, 95% CI: 1.15-5.00, p = 0.02) while patient with coronary artery disease were more likely to be overtreated (OR 4.00, 95% CI: 1.61-10.00, p = 0.03). Undertreated patients had an increased risk for all-cause mortality [hazard ratio (HR) 2.96, 95% CI 1.81-4.82: p = 0.00001] and cardiovascular mortality (HR 3.16, 95% CI: 1.49-6.68, p = 0.003).
  
  
  CONCLUSIONS
  In this single centre cohort of patients undergoing PTA, suboptimal antithrombotic therapy was not uncommon and had a major impact on long-term outcomes, resulting in increased all cause and cardiovascular mortality.
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.
authors.forename: D M S
authors.initials: DM
authors.lastname: Bodansky
authors.forename: I R
authors.initials: IR
authors.lastname: Allon
authors.forename: S
authors.initials: S
authors.lastname: Apostolakis
authors.forename: G Y H
authors.initials: GY
authors.lastname: Lip
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000706:statistics & numerical data*; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D000077144:Clopidogrel; D015331:Cohort Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000150:complications* / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D012189:Retrospective Studies; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin