These are all compelling points. Is the ticagrelor effect obscured by the relatively mild nature of the peripheral vascular disease in the study population? The average ABI was 0.71 and the majority of patients were claudicants or asymptomatic. Fewer than 5% of patients had CLI. Certainly, in vascular surgery studies looking at survival, graft patency, and a host of related endpoints patients with CLI behave very differently from claudicants. Indeed, studies with different admixtures of these two have appeared to show different results when this has been ignored. As a corollary point, the exclusion of patients on dual antiplatelet therapy or anticoagulation would exclude patients with some of most advanced disease: high-risk bypasses, tibial stents, etc. Looking at the subgroup analysis, however, there is no obvious trend with respect to the primary endpoint between different Rutherford’s classes. These results make sense when, for example, postulating a threshold effect attained by clopidogrel beyond which additional platelet inhibition is not beneficial. Experts, what are your thoughts? What do you think about the study population?
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