Background: Clopidogrel monotherapy is guideline-recommended in symptomatic peripheral
artery disease (PAD). The advent of new antithrombotic strategies prompts an updated
analysis of available evidence on antiplatelet therapy for PAD.
Methods: We searched MEDLINE, Embase and CENTRAL through January 2019 for randomised
controlled trials and observational studies comparing antiplatelet therapies as monotherapy, dual
therapy, or combination with anticoagulants. Efficacy (major adverse cardiovascular events, acute
or chronic limb ischaemia, vascular amputation, peripheral revascularisation) and safety (all-cause
mortality and overall bleeding) outcomes were evaluated via Bayesian network meta-analyses.
Results: We analysed 26 randomised controlled trials. Clopidogrel (hazard ratio, HR, 0.78; 95%
credible interval [CrI] 0.65-0.93) and ticagrelor (HR 0.80; 95% CrI 0.65-0.98) significantly reduced
major adverse cardiovascular events risk compared with aspirin. No significant difference
was observed for dual antiplatelet therapy with clopidogrel and aspirin. Vorapaxar significantly reduced
limb ischaemia and revascularisation compared with placebo, while dual antiplatelet therapy
with clopidogrel and aspirin showed a trend for reduced risk of amputation compared with aspirin
(risk ratio 0.68; 95% CrI 0.43-1.04). For all-cause mortality, picotamide, vorapaxar, dipyridamole
with aspirin, and ticlopidine showed a significantly lower risk of all-cause mortality vs aspirin.
Clopidogrel and ticagrelor showed similar overall bleeding risk vs aspirin, while dual antiplatelet
therapy with clopidogrel and aspirin significantly increased bleeding risk.
Conclusion: This updated network meta-analysis confirms that clopidogrel significantly decreases
the risk of major adverse cardiovascular events compared with aspirin, without increasing bleeding
risk. Clopidogrel should remain a mainstay of PAD treatment, at least in patients at higher bleeding