Curbside Consults Podcast

Published May 29, 2020

Peripheral artery disease (PAD) affects some 200 million persons worldwide. Current guidelines recommend antiplatelet monotherapy for the majority of cases, and dual antiplatelet therapy – commonly aspirin and clopidogrel – for endovascular interventions.  Even with these, limb events and complications remain high for this subgroup of patients. 

Research and practice to date have grown out of findings for PAD subgroups in cardiovascular trials. Although they share risk factors, peripheral artery disease patients are distinct from coronary artery disease populations. The Vascular Outcomes Study of Aspirin Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD or VOYAGER PAD trial recently published in the NEJM puts a focus on this unique group of patients. 

In today’s podcast we are joined by Dr. Marc Bonaca to discuss the findings of the recent VOYAGER PAD trial and the use of low-dose rivaroxaban in peripheral artery disease after revascularization.

0:48 – Topic introduction
1:48 – Introduction of panelist
2:45 – Causes of PAD
3:30 – Risk factors for PAD
5:47 – Current treatment options for PAD and why revascularization procedures increase limb risk
10:28 – Goal and design of trial: Choosing to study PAD patients
13:29 – Choosing rivaroxaban as the study drug
16:29 – Engaging multinational trial sites
18:58 – Translating study findings to practice: the target audience
21:57 – Choosing the 5-point composite study outcome: Acute limb ischemia, major amputation of vascular cause, myocardial infarction, ischemic stroke, cardiovascular death
24:35 – Discussion of risk reduction: actual vs relative
26:26 – Safety outcome of bleeding and assessing the risk-benefit ratio
29:02 – Difference in outcome between claudicant and critical limb ischemia patient populations
30:00 – Discussion of future areas of study: graft patency and others
31:53 – Summary of take-home points
32:51 – Conclusion and thanks

Resources and articles discussed in this episode:

1. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease (COMPASS trial)
2. EUCLID trial: Ticagrelor versus Clopidogrel in Symptomatic Peripheral Artery Disease
3. CAPRIE trial: A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE)
4. BOA trial: Dutch Bypass Oral Anticoagulation
5. FOURIER trial: Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease

The Curbside Consults series complements the foundational information in Rotation Prep by taking a deep dive into key clinical topics with expert clinicians and educators. These podcasts explore and critique the evidence behind clinical practice and break down statistical concepts for the busy clinical trainee.

Dr. Marc Bonaca Cardiologist and Vascular Medicine Specialist; and an Associate Professor and Director of Vascular Research at the University of Colorado School of Medicine and CPC Clinical Research, Aurora, Colorado.  He is the inaugural William R. Hiatt Endowed Chair in Cardiovascular Research of the University of Colorado Anschulz School of Medicine. 
Krista is a 2019-2020 editorial fellow at the New England Journal of Medicine. She is from Nassau, Bahamas where she is training in general surgery at the University of the West Indies.