Letter by Moris et al Regarding Article, “Ticagrelor Compared With Clopidogrel in Patients With Prior Lower Extremity Revascularization for Peripheral Artery Disease”
Authors: Demetrios Moris, Nikolaos Patelis, Stavros Kakkos
Journal: Circulation (2017)

We read with great interest the work by Jones et al 1 evaluating the efficiency of ticagrelor as an antithrombotic regimen for long-term management in patients with symptomatic peripheral artery disease (PAD) with a history of limb revascularization.Despite overwhelming data demonstrating the efficacy of antiplatelet therapy in heart disease and stroke, data in PAD are still scarce.Aspirin has modest evidence supporting a reduction in cardiovascular events in patients with PAD, whereas clopidogrel monotherapy may be more effective in PAD.Ticagrelor is beneficial in patients with acute coronary syndrome and prior myocardial infarction without solid evidence for its role in PAD. 2 A recent trial, however, demonstrated that in stable patients after myocardial infarction with concomitant PAD, ticagrelor reduced major adverse cardiovascular effects and acute limb ischemia episodes compared with aspirin monotherapy. 3s this article suggests, 1 ticagrelor did not reduce the primary composite end point of cardiovascular mortality, myocardial infarction, or ischemic stroke compared with clopidogrel in patients with PAD and a history of lower extremity revascularization. 1 It would be of interest if the authors could provide more data on the role and efficiency of ticagrelor in the subgroup of patients without previous limb revascularization.Is there any benefit with ticagrelor in these patients?Moreover, when the subgroups of patients are compared on the basis of the time since the most recent lower extremity revascularization, is there any group of patients with greater benefit from clopidogrel or ticagrelor?Recent data demonstrated that ticagrelor is superior in terms of in-stent restenosis compared with clopidogrel in patients with acute coronary disease undergoing percutaneous coronary intervention with an increase in minor bleeding rates. 4Did the authors find any change in restenosis rates after revascularization between the 2 medications in the revascularization group?Are there any differences between the open and endovascular revascularization approaches?Current literature concludes that ticagrelor has been shown to be clinically superior to clopidogrel in patients with myocardial infarction, but the underlying mechanisms of its superiority remain elusive.Ticagrelor may exert off-target effects through adenosine-dependent mechanisms or by inflammation reduction. 5ll in all, we are going through an era of individualization of medical treatment of vascular diseases.In fact, medical and surgical treatment of vascular diseases in general is now more personalized than ever before, and different problems are treated differently.The reality is that even patients with similar problems can sometimes be treated differently.The commonplace finding of the current literature on the role of ticagrelor in patients with PAD is that it is not superior to clopidogrel in terms of major adverse cardiovascular effects and acute limb ischemia events and possibly inferior in terms of minor bleeding.It might be an option for patients at low risk of bleeding and decreased clopidogrel effectiveness.