Medical management of stable peripheral artery disease: the COMPASS trial. Perspectives from a vascular standpoint.

The late-breaking presentation of the COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial at the European Society of Cardiology Congress in 2017 with a simultaneous publication in The New England Journal of Medicine described important information on the relative risk/benefit of combining anticoagulation with antiplatelet therapy in both coronary artery disease and/or peripheral artery disease (PAD) patients. In this special article, a review of the literature addressing the effects of antiplatelets and anticoagulants in symptomatic PAD patients focusing on the two most relevant clinical endpoints: major adverse cardiovascular events and major adverse limb events is addressed. In addition, a critical review of the COMPASS trial results, with emphasis on the PAD population is performed from a vascular surgery standpoint. It is concluded that this important study validated the combined anticoagulation/antiplatelet strategies in the management of vascular disorders including stable atherosclerotic patients. However, challenges in implementing this strategy in clinical practice are expected, with bleeding complications still remaining as major concern, particularly for vascular surgeons. Further studies with different combinations of different anticoagulants/antiplatelets, eventually on top of new strategies such as PCSK9 inhibition are warranted to address the significant unmet medical need in this population of symptomatic atherosclerotic patients.