ESC Focus on Interventions & PC - 16

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34% greater risk of death [Genereux P et al. J Am Coll
Cardiol. 2014]. In the ARTE trial, aspirin monotherapy
reduced the risk of life-threatening/major bleeding following TAVR with no increase in the risk of stroke or
myocardial infarction compared with dual therapy (aspirin plus clopidogrel); however, the size of the trial was
small [Rodes-Cabau J et al. JACC Cardiovasc Interv.
2017]. Other trials are ongoing.
AF is present in about 30% to 40% of TAVR patients
and it confers an increased risk of stroke and bleeding.
Treatment choices include LAA occlusion (currently
tested in the Watch-TAVR study) and pharmacologic
therapy. Until results of reliable randomised studies are
available, anticoagulation remains standard therapy in
this situation according to current guidelines and available evidence in the absence of contraindications.

Multiple studies have also shown that PAD patients
may be undertreated. Although PAD is associated with
high ischaemic risk, patients may be less intensively
treated with antiplatelet therapy and statins relative to
MI patients (Figure 1; 60% vs 95%).
MI patients had a higher incidence of MI at 6 months
than PAD patients (5.5% vs 1.2%); however, the rate
of non-CV-related mortality was higher among PAD
patients. At 3 months, about 6.6% of MI patients had
died of non-CV-related causes, and this was doubled
in the PAD population. And at 3 years, about 10% of
patients in both groups had died of a CV cause. The
cause was related to coronary events in 69% of MI
patients and in 43% of PAD patients.
Because PAD patients are less likely to have an MI,
risk prevention should extend beyond preventing only
coronary ischaemic events, she concluded.

Outcomes and Management in
Patients With Peripheral Arterial
Disease and Cardiac Disease

PAD Patients With CAD
Many PAD patients also have concomitant CAD, said
Jeffrey Berger, MD, MS, NYU Langone, New York, New
York, USA. And because of their increased risk of incident
CV events, intensive secondary prevention strategies are
a key treatment focus for patients with both conditions
[Bonaca MP et al. J Am Coll Cardiol. 2016; Patel A et
al. Eur J Prev Cardiol. 2015]. He presented data from
a subgroup analysis from the EUCLID trial [Berger JS
et al. Am Heart J. 2016], showing that a history of CAD
in patients with symptomatic PAD increases the risk
for major adverse cardiac events. After multivariable
adjustment, there was a statistically significant increase
in the primary outcome (composite of CV death, MI, or
ischaemic stroke) in PAD patients with CAD compared
with in those without CAD (15.3% vs 8.9%; P = .005).
Dr Berger noted that this increase was driven by the
endpoint of MI, where patients with concomitant CAD
and PAD were more than 2-fold likely to develop an MI
than those with PAD alone. However, there was no significant difference between the 2 groups with respect
to the rates of ischaemic stroke, CV death, acute limb
ischaemia, TIMI major bleeding, or intracranial bleeding.
The study also showed that monotherapy with ticagrelor does not reduce the composite endpoint of CV and
acute limb events when compared with clopidogrel (15.4%
vs 15.3%; P = .84). And there were no significant differences between the treatment groups with respect to safety
endpoints of TIMI major bleeding or TIMI minor bleeding.

Written by Nicola Parry

Peripheral arterial disease (PAD) and cardiac disease are
associated with significant health burdens [Sampson UK
et al. Glob Heart. 2014; Roth GA et al. J Am Coll Cardiol.
2017], and the prevalence of both diseases (polyvascular disease) increases with age. As the population ages
the number of patients with these diseases is expected
to continue to rise over the coming decades.
In the PAD and Cardiac Disease - A Permanent CrossTalk symposium on 27 August 2017, several speakers
discussed outcomes and management in PAD patients
who also have concomitant cardiac diseases, including
coronary artery disease (CAD), atrial fibrillation (AF),
and heart failure (HF).
Patient Outcomes in PAD Versus MI
Birgitta Sigvant, MD, PhD, Karolinska Institute,
Stockholm, Sweden, emphasised that although ischaemic heart disease is the leading cause of death worldwide, PAD is one of the most prevalent cardiovascular
(CV) diseases [Roth GA et al. J Am Coll Cardiol. 2017;
Fowkes FG et al. Lancet 2013].
However, the differences in comorbidity, CV outcomes, and mortality have been increasingly appreciated and described in a number of publications. Reporting
data from a study that compared these factors among
incident myocardial infarction (MI) and PAD patients,
Dr Sigvant noted that these 2 patient groups differed
at first manifestation of atherosclerotic disease: PAD
patients were older (69.3 vs 66.0 years), more likely to
be female (45% vs 31%), and had a higher prevalence of
conditions such as stroke (10% vs 5%), diabetes (30%
vs 22%), and AF (14% vs 7%).

October 2017

PAD Patients With AF
Prof Christine Espinola-Klein, University Medical Center,
Mainz, Germany, discussed the frequent co-prevalence
of PAD and AF in older patients. And Antonios Vitalis,
MD, University of Birmingham, Birmingham, United
Kingdom, presented data from the AFFIRM study which
investigated the prevalence of PAD in AF patients and
associated outcomes [Vitalis A et al. Eur Heart J. 2017].
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