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Medical management of peripheral arterial disease.

To the Editor: In their Clinical Review, Dr Hankey and colleagues discussed medical management for peripheral arterial disease (PAD), which they document as a strong risk factor for cardiovascular morbidity and mortality. While I agree with their advice that all patients with this condition warrant treatment with an antiplatelet drug, I disagree with their statement that aspirin is “the preferred antiplatelet drug because it is effective and inexpensive.” Two active comparator randomized trials showed that alternative antiplatelet agents—clopidogrel and picotamide—were superior to aspirin for the prevention of cardiovascular events in patients with PAD. In patients with both PAD and type 2 diabetes mellitus, picotamide reduced the risk of death by 45% in comparison with aspirin (relative risk [RR], 0.55; 95% confidence interval [CI], 0.31-0.98). Moreover, in the Clopidogrel vs Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial, clopidogrel reduced the cardiovascular event rate by 24% in comparison with aspirin (RR, 0.76; 95% CI, 0.64-0.91). Finally, a formal economic analysis based on the CAPRIE data concluded that clopidogrel was cost-effective for patients with PAD.