During Thursday’s Hot Topics session, John Curci, MD, an associate professor of surgery at Washington University School of Medicine, discussed the changing landscape of long-term antiplatelet and anticoagulant use in the management of peripheral artery disease (PAD) in light of results from the AQUATIC trial.
The AQUATIC trial evaluated whether adding aspirin to direct oral anticoagulants improved cardiovascular and limb-related outcomes in high-risk vascular patients or if they actually increased bleeding risk without providing sufficient meaningful benefit.
Researchers enrolled over 800 patients across 51 institutions in France, focusing on those with advanced atherosclerotic disease, including PAD, carotid disease and coronary artery disease. All patients were being treated with long-term anticoagulation therapy, most commonly to reduce cardioembolic risk of atrial fibrillation. Patients were randomized to continue aspirin therapy or receive a placebo in addition to their anticoagulant regimen.
Results showed that bleeding complications were more common in patients taking aspirin and anticoagulants, which Curci said was expected. “What wasn’t so obvious before the trial was that the patients who were on both an aspirin and a direct oral anticoagulant had more arterial occlusive events, either emboli, strokes, heart attacks or needed leg intervention than those on oral anticoagulation alone,” he said. “This was a remarkable finding.”
The mortality findings were particularly striking, Curci said. All-cause mortality reached 13.4% in patients who continued aspirin, compared to 8.4% in patients receiving placebo. This was among the reasons that the trial was stopped early for safety reasons.
Curci said the data has direct implications for long-term medical management in PAD patients, particularly as surgeons increasingly manage complex antiplatelet and anticoagulant regimens. “If a patient requires direct oral anticoagulation therapy, the addition of aspirin does not provide any additional benefit to reduce the risk of future coronary or lower extremity vascular events.”
The findings also raise broader questions about how antithrombotic strategies should be tailored across different conditions. Curci said that cerebrovascular disease may respond differently to anticoagulants and antiplatelet therapies than coronary or lower extremity disease, suggesting future studies may need to evaluate these outcomes separately.
The study did not enroll patients who had a coronary intervention within 6 months prior to enrollment which leaves unanswered questions surrounding perioperative antithrombotic management, according to Curci. “For our PAD patients, we need to develop better evidence about antiplatelet and anticoagulant therapies in the periprocedural period to determine what is optimal, both in safety and in reducing the risks of future events.”
