2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

. Author manuscript; available in PMC: 2017 Sep 21.

Published in final edited form as: Circulation. 2016 Nov 13;135(12):e726–e779. doi: 10.1161/CIR.0000000000000471


Recommendations for Oral Anticoagulation

COR	LOE	Recommendations

IIb	B-R	The usefulness of anticoagulation to improve patency after lower extremity autogenous vein or prosthetic bypass is uncertain.^193–195

See Online Data Supplements 23 and 24.		Two RCTs evaluating the effectiveness of oral anticoagulation (warfarin) in improving lower extremity bypass patency demonstrated improved patency among the subgroup of patients with autogenous vein bypass grafts.^193,194 However, a Cochrane systematic review showed no patency benefit with the use of anticoagulation compared with antiplatelet therapy.¹⁹⁵ All RCTs and observational studies evaluating the effect of anticoagulants on bypass patency demonstrated increased bleeding complications associated with anticoagulant use. One RCT evaluating the effectiveness of oral anticoagulation (warfarin) in addition to aspirin in improving lower extremity bypass patency demonstrated improved patency in a subgroup of patients with 6-mm polytetrafluoroethylene (known as PTFE) bypass graft.¹⁹⁶ Randomization to anticoagulation plus aspirin was associated with increased risk of death and major hemorrhage versus aspirin alone.

III: Harm	A	Anticoagulation should not be used to reduce the risk of cardiovascular ischemic events in patients with PAD.^{194,196–198}

See Online Data Supplements 23 and 24		RCTs and observational studies have uniformly demonstrated that oral anticoagulation therapy aimed at decreasing major cardiovascular ischemic events provided no benefit and resulted in increased morbidity.^{194,196–198} In the WAVE (Warfarin Antiplatelet Vascular Evaluation) trial of patients with atherosclerotic vascular disease, including PAD, there was no difference in cardiovascular ischemic events among patients randomized to oral anticoagulation and antiplatelet therapy versus antiplatelet therapy alone.¹⁹⁸ In addition, there was an increase in bleeding endpoints including life-threatening and intracranial bleeding.¹⁹⁸ One RCT demonstrated increased death rate among patients randomized to warfarin plus aspirin versus aspirin alone after lower extremity bypass grafting.¹⁹⁶