LAUSR

Conclusions: After adjustment for baseline characteristics, patients with symptomatic peripheral artery disease (PAD) based on prior revascularization, rather than an abnormal ABI, had a higher rate of myocardial infarction (MI) and acute limb ischemia but with a similar composite rate of cardiovascular death, MI and stroke. No significant difference was found between ticagrelor and clopidogrel for reduction of cardiovascular or acute limb ischemic events. Summary: The EUCLID trial (Examining Use of Ticagrelor vs Clopidogrel In PAD) randomized 13, 885 patients with peripheral artery disease to treatment with ticagrelor 90 mg twice daily or clopidogrel 75 mg daily. Patients were enrolled based on an abnormal ankle-brachial index #0.80 or a previous lower extremity revascularization. This analysis focuses on the 7875 (57%) patients enrolled based on the previous lower extremity revascularization criterion. Important exclusion criteria were that patients could not be enrolled within 30 days of most recent revascularization nor if on dual antiplatelet therapy. The primary efficacy end point was a composite rate of cardiovascular death, MI, or ischemic stroke. The primary safety end point was major bleeding. Patients with a previous revascularization had a mean age of 66 years, 73% were male, and the median baseline ankle-brachial index was 0.78. When compared to those entered into the study based on ABI criteria, there was a lower % of women (27% vs 29.3%; P 1⁄4 .004) but higher % of carotid stenosis (19% vs 15.3%; P 1⁄4 .001), prior coronary intervention (26.3% vs 19.1%; P 1⁄4 .001), and multilevel vascular disease (46.2% vs 40.7%; P 1⁄4 .001). They were more commonly smokers, hyperlipidemia and more were being treated with cardioprotective medications (antiplatelets, statins) prior to enrollment. There were fewer diabetics in this group. 31.3% were asymptomatic while 4.5% were experiencing critical limb ischemia. 63.5% had endovascular revascularization while 36.3% required an open operation. The timing of most recent revascularization was nearly a third of patients in each of three time intervals: <6 months, 6-24 months, and >2 years. 7.5% of patients had prior amputation; 1.7% above knee, 1.1% below knee and the remainder less extensive. Compared with patients enrolled based on the ABI criterion, patients enrolled based previous revascularization had higher rates of the primary composite end point (11.4% vs 9.9%; P 1⁄4 .02), myocardial infarction (5.9% vs 3.6%; P < .001), acute limb ischemia (2.5% vs 0.6%; P < .001), and major bleeding (1.8% vs 1.3%; P 1⁄4 .01). After adjustment for baseline characteristics, patients enrolled based on previous revascularization vs those with abnormal ABI criteria had similar rates of the primary composite end point (P 1⁄4 .12) but significantly higher rates of myocardial infarction (P 1⁄4 .005) and acute limb ischemia (P < .001). Ticagrelor was not found to statistically improve the rates of primary or secondary efficacy or primary safety end points vs clopidogrel treatment: primary efficacy end point (11.4% vs 11.3%; P 1⁄4 .90), all-cause mortality (9.2% vs 9.2%; P 1⁄4 .93), acute limb ischemia (2.5% vs 2.5%; P 1⁄4 .84), or major bleeding (1.9% vs 1.8%; P 1⁄4 .41). The bleeding rate was no different for intracranial bleeds (both 0.6%), fatal bleeds (0.1% ticagrelor vs 0.3% clopidogrel) or minor bleeds (1.6% ticagrelor vs 1.3% clopidogrel). The median duration of follow-up was w30 months with 19 patients either lost to follow-up or of unknown status. Comments: This subgroup analysis of the EUCLID study provides some insight into the care of patient with a prior revascularization. We must be more aware of the increased risk of myocardial infarction in these patients since it affects our attention and intensity of medical treatment. The increased incidence of acute limb ischemia is more difficult to interpret since we do not know the specific type of revascularization (angioplasty, bypass (synthetic or autogenous), location, etc.), which would affect the type of medical adjuvants we might chose to improve patency. The bottom-line for this study, however, is that either of these antiplatelets have a similar effect on cardiovascular risk reduction. It adds understanding to our use of monotherapy in these patients but much work needs to be done to determine optimal therapy. CD98 Regulates Vascular Smooth Muscle Cell Proliferation in Atherosclerosis Baumer Y, McCurdy S, Alcala M, Mehta N, Lee BH, Ginsberg MH, et al. Atherosclerosis 2017;256:105-14.