Shout outs to @GBarnesMD @DLBHATTMD @cpcannon @MichaelJBlaha @CarlosMenaYale @JudithLin4 @JRUNMD @cmaflah @GaryRaskob @ShariqShamimMD and a reminder that past programs–still available for credit–can be found at https://t.co/vyVIMA8cMd
— cardio-met (@cardiomet_CE) July 19, 2021
1) Welcome to a tweetorial on medical management after lower extremity revascularization for symptomatic #PAD. This tweetorial is accredited for 0.50 CE/CME credits by @academiccme: #physicians, #nurses, #pharmacists! Expert faculty @MarcBonaca pic.twitter.com/Bpvmqudsmc
— cardio-met (@cardiomet_CE) July 20, 2021
3) 68F with lower extremity PAD and severe lifestyle limiting claudication. She completed supervised exercise with some benefit but still limited and can only walk 1 block. She tried cilostazol but did not find it beneficial, had GI symptoms, and stopped. She is a former smoker.
— cardio-met (@cardiomet_CE) July 20, 2021
5) Other PMH: She has coronary disease, had a PCI to her LAD 18 months ago, and is on aspirin monotherapy; T2D on metformin with Hgb A1C 7.9%, hyperlipidemia with LDL-C of 76 on rosuvastatin 20mg QD. Creat 1.2.
— cardio-met (@cardiomet_CE) July 20, 2021
7) POLL: What is an optimal LDL-C target for this patient?
— cardio-met (@cardiomet_CE) July 20, 2021
a)Ideally to ~30 mg/dL
b)< 55 mg/dL
c)< 70 mg/dL
9) POLL: Would you intensify her antithrombotic therapy?
— cardio-met (@cardiomet_CE) July 20, 2021
a)Yes
b)No
10) Please answer the five polling questions and return tomorrow for more education and more on this case! @brianrosePAS @bbikdeli @drbarryrubin @KHowse2014 @TL_Forbes @WeiZhou74370988 @BruceTjadenMD @ahmedkayssi @Lross246 @VietHeartPA
— cardio-met (@cardiomet_CE) July 20, 2021
12) . . . or < 55 mg/dL (ESC); however, data from recent trials show benefits for MACE and limb outcomes down to very low LDL-C levels of ~30 mg/dL or lower with no significant safety concerns.
— cardio-met (@cardiomet_CE) July 21, 2021
14) Current Guidelines give a class I indication to ASA or clopidogrel monotherapy for chronic symptomatic PAD. Vorapaxar is approved to be added to ASA and/or clopidogrel for MACE reduction and has a class IIb recommendation.
— cardio-met (@cardiomet_CE) July 21, 2021
16) POLL: Which therapy would you change first?
— cardio-met (@cardiomet_CE) July 21, 2021
a) LDL-C lowering
b) GLP1a and/or SGLT2i
c) Antithrombotic intensification
d) I wouldn’t change anything
18) You decide to do an angiogram to evaluate her anatomy with the left SFA image shown below. pic.twitter.com/nJlt5epFlR
— cardio-met (@cardiomet_CE) July 21, 2021
20) POLL: If you would – which option would you recommend??
— cardio-met (@cardiomet_CE) July 21, 2021
a) Yes with endovascular revascularization
b) Yes with bypass using GSV
c) Yes with bypass using prosthetic graft
d) Yes with endarterectomy only
22) She is planned for endovascular revascularization. What antithrombotic strategy would you utilize before/during intervention?
— cardio-met (@cardiomet_CE) July 21, 2021
POLL:
a) Aspirin only
b) Aspirin and P2Y12 inhibition
c) Aspirin and an anticoagulant
d) Aspirin, P2Y12 inhibition and an anticoagulant
24) Drug coated products are associated with better patency over time. A meta-analysis observed an association with mortality but several subsequent observational studies have not confirmed a mortality risk.
— cardio-met (@cardiomet_CE) July 21, 2021
26) Current guidelines give no Class I recs for antithrombotic therapy after lower extremity revascularization. Although DAPT (ASA+clopidogrel) is often used after endovascular revasc, the RCT exploring this regimen (CAMPER) never recruited . . .
— cardio-met (@cardiomet_CE) July 21, 2021
28) Anticoagulation after bypass, similarly, showed no benefit for graft patency in the DUTCH BOA trial but more bleeding.
— cardio-met (@cardiomet_CE) July 21, 2021
30) What is your standard practice? Do you use DAPT after endovascular lower extremity revascularization for symptomatic PAD?
— cardio-met (@cardiomet_CE) July 21, 2021
POLL:
32) Please mark your answers and return tomorrow for more data/analysis, a wrap-up of this case, and a link to your credit! @Hragy @SABOURETCardio @mmamas1973 @JimGMelton @maciejbanach @realMorrisseyMD @drpablocorral @ashkan_1670 @VascularMDKalsi @BillBeckerman @ProleneQueen
— cardio-met (@cardiomet_CE) July 21, 2021
34) Would you add rivaroxaban 2.5 mg twice daily to aspirin or DAPT after endovascular revascularization?
— cardio-met (@cardiomet_CE) July 22, 2021
POLL:
36) If using triple therapy (aspirin, clopidogrel, rivaroxaban 2.5 mg twice daily) how long would you continue clopidogrel?
— cardio-met (@cardiomet_CE) July 22, 2021
POLL:
38) The efficacy and safety of riva was consistent regardless of background clopi. There was a ~50% reduction in acute limb ischemia with riva early and late regardless of clopi use. Extended duration of clopi (>1 month) was associated with a trend towards more bleeding.
— cardio-met (@cardiomet_CE) July 22, 2021
40) Clopidogrel was stopped 1 month after intervention and she continues on aspirin and rivaroxaban 2.5 mg twice daily. How long after intervention would you continue this antithrombotic strategy?
— cardio-met (@cardiomet_CE) July 22, 2021
POLL:
42) There is no exact answer! Symptomatic PAD patients are at extremely hi risk of limb complications partic for the first 12-18 mths after intervention; however, they remain at ~4 fold risk of ALI even long-term relative to symptomatic PAD patients who have ever had revasc.
— cardio-met (@cardiomet_CE) July 22, 2021
44) When counting total events, the risk is much higher. See Total Ischemic Event Reduction with Rivaroxaban after Peripheral Arterial Revascularization in the VOYAGER PAD Trial, just released at https://t.co/InFTgI7IDo.
— cardio-met (@cardiomet_CE) July 22, 2021
46) Key concept (c) Adding low dose rivaroxaban (2.5 mg twice daily) to ASA and/or DAPT after revascularization reduces this risk and increases bleeding but with a 6:1 benefit risk ratio. (d) Longer term use of this regimen in stable chronic PAD also reduces MACE and mortality.
— cardio-met (@cardiomet_CE) July 22, 2021
47) That's it! You made it! Free CE/#CME! #Physicians, #nurses, #pharmacists: go to https://t.co/rrqi2uGxFn and claim your credit! I am @MarcBonaca. Follow us for more tweetorials! #Medtwitter #MedEd @MedTweetorials #FOAMed @CardioNerds #CardioTwitter @SABOURETCardio @mmamas1973 pic.twitter.com/RSXAKbJaBP
— cardio-met (@cardiomet_CE) July 22, 2021