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Purpose of Review: Patients who require urgent or emergent peripheral revascularization represent one of the highest risk subgroups of PAD patients. They suffer unacceptably high complication rates including recurrent ALI, vascular amputation, and death. In this article, we examine (1) the burden of cardiovascular complications according to PAD severity, (2) discuss medical optimization to improve vascular outcomes in symptomatic LE-PAD patients, and (3) review the evidence for management of patients following urgent/emergent limb ischemia., Recent Findings: The VOYAGER trial recently demonstrated that rivaroxaban 2.5 mg BID + ASA daily significantly reduces major adverse cardiac and limb events in patients following lower extremity revascularization. A recent Canadian survey also demonstrated that significant heterogeneity exists in antithrombotic prescribing practices following urgent/emergent revascularization. COMPASS and VOYAGER have demonstrated the efficacy of aspirin 81 mg daily and rivaroxaban 2.5 mg twice daily at reducing MACE and MALE events in stable PAD patients and those undergoing elective revascularization. Patients who require urgent or emergent peripheral revascularization remain the highest thrombotic risk subgroup of PAD patients, in whom there is insufficient evidence to guide antithrombotic therapy. Despite clear evidence that multi-modal medical therapy (including statins, antihypertensive agents and smoking cessation) benefits patients with atherosclerosis, their use remains unacceptably low in PAD, and greater efforts are needed to understand and address patient, health provider, and system issues that prevent their optimal implementation in practice.

Purpose of Review: Peripheral artery disease (PAD) affects an estimated 200 million people worldwide and is associated with significant cardiovascular morbidity and mortality. Cardiovascular risk is further increased among individuals with polyvascular disease, where either cerebrovascular or coronary artery disease is present in addition to PAD. In this review, we present common clinical scenarios encountered when managing patients with PAD and provide an evidence-based approach to prescribing optimal antithrombotics in this population., Recent Findings: The COMPASS trial recently demonstrated that rivaroxaban 2.5 mg BID + ASA daily significantly reduces major adverse cardiac and limb events in patients with PAD. Despite these advances, morbidity following MALE events remains high. With widespread approval by federal health regulators, the COMPASS regimen should be strongly considered in PAD patients who do not have a high bleeding risk. Implementing the COMPASS regimen in patients with PAD, along with other vascular risk reduction strategies, will have a substantial impact on reducing atherothromboembolic risk in patients with established vascular disease.

Current guidelines include atrial fibrillation (AF) catheter ablation as part of the management strategy in patients that have failed at least one oral antiarrhythmic drug treatment course. However, growing evidence derived from both randomized and non-randomized studies demonstrate lower rates of AF recurrence and AF burden in patients with paroxysmal AF that are naïve to antiarrhythmic drug treatment. Furthermore, progression from paroxysmal AF to persistent AF appears to be delayed by early catheter ablation of AF. The current review addresses the question of the best timing for ablation in patients with paroxysmal AF and provides the rationale for offering AF ablation as first-line therapy based on the most updated evidence available.

In STEMI, primary PCI restores macrovascular coronary blood flow effectively but microvascular perfusion remains a challenge. Thrombus has the potential to embolize to the microvasculature limiting effective coronary blood flow. Thrombus burden is associated with a higher mortality and manual aspiration thrombectomy has the potential to reduce thrombus burden. The first large trial of routine aspiration thrombectomy (TAPAS, N = 1071) showed an improvement in myocardial blush and an unexpected reduction in mortality. Reinforcing the enthusiasm for this finding meta-analysis of small trials also showed a reduction in mortality, which led to routine manual thrombectomy becoming a class IIa recommendation in the American and European Guidelines for STEMI. Subsequently; however, large trials such as TOTAL (N = 10,732) and TASTE (N = 7244) and meta-analysis showed an increase in the risk of stroke with routine manual thrombectomy but no improvement in mortality, myocardial infarction, stent thrombosis, or severe heart failure. As such, manual thrombectomy should not be routinely used instead saving it as a bailout procedure as indicated.

Heparin-induced thrombocytopenia (HIT) is a syndrome of antibody-mediated activation of platelets and coagulation that confers increased risk for thrombosis. This article reviews recent studies of the pathogenesis, laboratory testing, frequency, and clinical presentation of HIT. Topics discussed include the nature of the neoepitopes on platelet factor 4 recognized by HIT antibodies, the nonspecific nature of the polyanions that support neoepitope formation, activation of monocytes and endothelium, and the development of new animal models. The transient "autoimmune" nature of HIT is highlighted in relation to new data concerning the rapid decline in HIT antibodies, as well as the recent recognition of a syndrome of "delayed-onset HIT" in which thrombocytopenia and thrombosis begin several days after stopping heparin. Detecting only HIT antibodies of the immunoglobulin G class is suggested as one way to increase diagnostic specificity of laboratory testing. Recent reports suggest that HIT could explain approximately 5% of cases of acute adrenal failure caused by bilateral adrenal hemorrhagic infarction.