Peripheral Arterial Disease and Atrial Fibrillation

Peripheral arterial disease (PAD) is a broader term that includes atherosclerotic involvement of arteries other than the coronary arteries and the aorta. In PAD, stenosis (narrowing) and eventually occlusion (closure) of peripheral arteries develop progressively. The main risk factors for PAD are similar to those for atrial fibrillation (AF):

Smoking
Diabetes mellitus
Arterial hypertension
Obesity
Dyslipidaemia

Peripheral arterial disease (PAD) – involvement of peripheral arteries
Peripheral arteries	Prevalence in PAD (%)
Lower extremity arteries	40 – 50 %
Carotid arteries	20 – 30 %
Upper extremity arteries	5 – 10 %
Renal arteries	5 – 10 %
Mesenteric artery	1 – 2 %

Illustration depicting atrial fibrillation with peripheral arterial disease of the lower limbs, atherosclerotic arterial involvement, and indication for anticoagulation with NOACs.

The prevalence of PAD in the population is 1–5% (>15% in older patients >80 years).

The term PAD is often used to refer to lower extremity PAD (LE-PAD), because LE-PAD is the most common form of PAD. In patients with AF, the most available data therefore relate to the combination of AF and LE-PAD.

LE-PAD is present in 6–14% of patients with AF.

The most common symptoms of LE-PAD:

Claudication (pain in the calf or thigh during walking that resolves after stopping)
21% of patients with claudication have critical limb ischaemia
Reduced temperature of the affected limb
Ulcers (that heal slowly)
Absent palpable pulses in the limb

High-risk LE-PAD is defined as:

Status after limb amputation
Critical limb ischaemia (rest pain, ulceration, gangrene)
Status after revascularization (balloon, stent, bypass).
The patient has comorbidities:

Heart failure
Diabetes mellitus
Vascular disease in at least 2 territories (coronary arteries, cerebral arteries, renal arteries, peripheral arteries, aorta)
Chronic kidney disease

Asymptomatic LE-PAD does not require antiplatelet or anticoagulation therapy.

If a patient has PAD and AF requiring anticoagulation therapy, anticoagulation therapy alone is given (without antiplatelet therapy).

For anticoagulation therapy, NOAC is preferred (not warfarin).

A patient with AF (with an indication for anticoagulation therapy), after revascularization for PAD

may transiently receive dual antithrombotic therapy for 1–3 months (e.g. NOAC + Aspirin),
then anticoagulation therapy alone is continued.

Peripheral arterial disease and atrial fibrillation	Class
In PAD and AF (requiring anticoagulation therapy), anticoagulation therapy alone (preferably NOAC) is recommended, without antiplatelet therapy.	I

PAD - Peripheral arterial disease NOAC – Non-vitamin K oral anticoagulants (Dabigatran, Rivaroxaban, Apixaban, Edoxaban)