Interactive tool
Optimal medical therapy in patients with arterial disease
Enter the picture in each arterial territory, the patient's data and the conditions that change the choice: the tool calculates creatinine clearance, CHA2DS2-VA and HAS-BLED, estimates the LDL achievable with each therapy step and proposes the regimen in order of priority. Everything runs in the browser, without transmitting or storing any data.
Step 1
Arterial territories
Current picture in each territory. The degree of carotid stenosis is NASCET; symptomatic pictures refer to ipsilateral ischaemic events.
Other atherosclerotic territories
Step 2
Patient data
Age, weight, sex and creatinine are needed for clearance (Cockcroft-Gault), doses and scores. LDL and current therapy are needed to estimate the lipid-lowering step required.
Lipid and glycaemic profile
Risk factors and comorbidities
Bleeding risk
Intolerances and interactions
Step 3
Text for the report
A ready-made sentence to paste into the conclusions. It describes the recommended therapy, not the current therapy.
Interpretation
How to read the result
The dark box summarises the calculated profile: cardiovascular risk category, territories involved, creatinine clearance, scores and targets. It is followed by the cross-cutting alerts and the cards for each therapeutic area, in the order in which the decisions should be taken: first antithrombotic therapy, then heparin when needed, then risk factors. In each card the first drug is the recommended choice; those marked Alternative are equivalent or fallback options, and the last card lists the drugs to avoid, with the reason.
When several territories are involved the tool does not add up the regimens: it chooses the most intensive one required by the most recent picture (for example dual antiplatelet therapy after a carotid stent or after PTA) and indicates the maintenance therapy that follows. An indication for anticoagulation prevails: in stable arterial disease the anticoagulant is used alone, without an antiplatelet agent.
Each drug shows the source and the class verified against the full texts: I recommended, IIa should be considered, IIb may be considered, III not recommended, followed by the level of evidence A, B or C. The Italian guidelines use GRADE strength strong / weak. Indications found only in the guideline text or not verified in the documents consulted are shown in grey. Where SICVE-SNLG and the European guidelines diverge (for example the duration of dual antiplatelet therapy after carotid stenting, three months instead of one) the tool follows the Italian guideline and says so.
From the current LDL and the current therapy the tool reconstructs the baseline LDL and applies the average expected reductions: high-intensity statin about −50%, adding ezetimibe about a further −25%, anti-PCSK9 or inclisiran about a further −50–60%, bempedoic acid about −20%. It is a group estimate: the individual response must be measured at the 4–6-week check.
It does not replace the neurologist's decision in acute stroke, or the cardiologist's decision on the duration of dual antiplatelet therapy after ACS or PCI. It does not check all drug interactions. For venous thromboembolism use the anticoagulant therapy selector; for the indication for carotid surgery, the SICVE-SNLG calculator.
Drugs
Alternatives and side effects
Summary of the drug classes proposed by the tool: main adverse effects, monitoring and alternative in case of intolerance or contraindication.
| Drug | Side effects to monitor | Monitoring and cautions | Alternative |
|---|---|---|---|
| Aspirin 75–100 mg | Dyspepsia, peptic ulcer and gastrointestinal bleeding, bronchospasm in NSAID-induced asthma | Gastroprotection with a PPI if GI risk; avoid NSAIDs | Clopidogrel 75 mg |
| Clopidogrel 75 mg | Bleeding, rash, rarely neutropenia or thrombotic thrombocytopenic purpura | Reduced efficacy in CYP2C19 poor metabolisers; with a PPI prefer pantoprazole (avoid omeprazole and esomeprazole) | Aspirin; in TIA/minor stroke ticagrelor + aspirin for 30 days |
| Ticagrelor 90 mg × 2 | Dyspnoea, bradyarrhythmias, bleeding, hyperuricaemia | Do not combine with strong CYP3A4 inhibitors; aspirin ≤ 100 mg | Clopidogrel |
| Rivaroxaban 2.5 mg × 2 + aspirin | Major and gastrointestinal bleeding | Contraindicated with previous intracranial haemorrhage, lacunar stroke or stroke in the last month; not recommended with CrCl < 15; AIFA treatment plan in Italy (12 months) | Antiplatelet monotherapy |
| DOAC full dose | Bleeding, dyspepsia (dabigatran) | Dose according to age, weight and CrCl; check renal function at least annually (more often if CrCl < 60) | VKA (warfarin) with INR 2–3; mandatory with a mechanical heart valve |
| Unfractionated heparin / LMWH | Bleeding, HIT, osteoporosis with prolonged use | Platelet count on days 4–14; reduced LMWH dose if CrCl < 30; aPTT or anti-Xa for heparin infusion | Fondaparinux; with HIT argatroban or bivalirudin |
| Statins (atorvastatin, rosuvastatin) | Myalgia, raised CK and transaminases, rarely rhabdomyolysis; slight increase in diabetes risk | Baseline CK and ALT; rosuvastatin max 20 mg if CrCl 30–59 and contraindicated if < 30; CYP3A4 interactions for atorvastatin | Different statin at a low dose or on alternate days, ezetimibe, bempedoic acid, anti-PCSK9 / inclisiran |
| Ezetimibe 10 mg | Gastrointestinal effects, raised transaminases in combination | Well tolerated; useful as a fixed combination with the statin | Bempedoic acid |
| Bempedoic acid 180 mg | Hyperuricaemia and gout, tendon rupture, slight rise in creatinine | Do not combine with simvastatin > 40 mg; caution in gout | Anti-PCSK9 / inclisiran |
| Anti-PCSK9 / inclisiran | Injection-site reactions, flu-like syndrome | In Italy, AIFA registry and specialist treatment plan | — |
| Icosapent ethyl 2 g × 2 | Atrial fibrillation, minor bleeding, oedema | Only with triglycerides 135–499 mg/dL on statin therapy | — |
| Metformin | Gastrointestinal effects, vitamin B12 deficiency, lactic acidosis (rare) | Reduce to 1000 mg if eGFR 30–44, stop if < 30, with dehydration and with contrast media if eGFR < 30 or acute kidney injury | SGLT2i, GLP-1 RA, DPP-4i |
| SGLT2 inhibitors | Genital infections, volume depletion, euglycaemic ketoacidosis | Stop 3 days before major surgery and during acute illness; foot surveillance (canagliflozin: amputation signal) | GLP-1 RA |
| GLP-1 RA (semaglutide, dulaglutide, liraglutide) | Nausea, vomiting, gallstones, pancreatitis; worsening of retinopathy (semaglutide) | Avoid with previous pancreatitis; ophthalmological check in proliferative retinopathy; AIFA Note 100 form in Italy | SGLT2i; tirzepatide |
| ACE inhibitors / ARBs | Cough (ACE inhibitors), hyperkalaemia, rise in creatinine, angioedema | Creatinine and potassium at 1–2 weeks; caution in bilateral renal artery stenosis | ARB if cough with an ACE inhibitor |
| Cilostazol 100 mg × 2 | Headache, diarrhoea, palpitations, tachycardia, oedema | Contraindicated in heart failure, unstable angina, myocardial infarction < 6 months and with ≥ 2 antithrombotics; reassess at 3 months. ESC 2024 does not give it a class | Naftidrofuryl 200 mg × 3 |
Bibliography
Sources
- ESC 2024 — Mazzolai L et al., Guidelines for the management of peripheral arterial and aortic diseases (Eur Heart J 2024;45:3538–700).
- ESVS 2023 carotid — Naylor R et al., Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease (Eur J Vasc Endovasc Surg 2023;65:7–111).
- SICVE-SNLG 261 — Diagnosis and treatment of extracranial carotid stenotic-occlusive disease and stroke prevention (in Italian), Italian National Guidelines System (ISS), 1 October 2021.
- ISO-SPREAD VIII — Stroke: Italian guidelines for prevention and treatment (in Italian), version of 21 July 2016.
- ESVS 2023 antithrombotic — Twine CP et al., Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases (Eur J Vasc Endovasc Surg 2023;65:627–89): not yet checked against the full text.
- GVG 2019 — Conte MS et al., Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.
- ACC/AHA 2024 — Gornik HL et al., guideline on lower-extremity peripheral artery disease (cilostazol, supportive therapy).
- ESC/EAS 2019 and 2025 focused update — dyslipidaemia guidelines (LDL targets, bempedoic acid, Lp(a), icosapent ethyl).
- ESC 2023 — Marx N et al., Guidelines for the management of cardiovascular disease in patients with diabetes (Eur Heart J 2023;44:4043–140); STRIDE trial (semaglutide in peripheral arterial disease, 2025).
- ESC 2024 — guidelines on hypertension and on atrial fibrillation (CHA2DS2-VA).
- Trials — CAPRIE, COMPASS, VOYAGER PAD, CHANCE, POINT, THALES, CASPAR, BOA, CLEAR Outcomes, FOURIER, ODYSSEY Outcomes.
- AIFA (Italy) — Note 13 (lipid-lowering drugs), Note 100 (glucose-lowering drugs), treatment plan for rivaroxaban 2.5 mg in peripheral arterial disease, registries for anti-PCSK9 and inclisiran; SmPCs of the individual medicines.
A quick-reference tool for healthcare professionals. It does not replace the original guidelines, the summaries of product characteristics or the specialist's clinical judgement. Recommendation classes and reimbursement criteria may change: always check the current version.