Antithrombotic therapy for lower limb peripheral arterial disease: A deep dive into guideline quality and recommendation diversity.

Background: This study systematically evaluates clinical practice guidelines (CPGs) addressing antithrombotic management in lower limb peripheral arterial disease (PAD), aiming to synthesize evidence-based insights for clinical decision-making.

Methods: We systematically identified CPGs published between January 2020 and January 2025 from electronic databases, guideline repositories, and professional association websites. Guideline quality and recommendation validity were assessed using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation-Recommendation Excellence (AGREE-REX), respectively. Antithrombotic recommendations were extracted and analyzed for consensus and divergence.

Results: 11 CPGs met the inclusion criteria. The AGREE II evaluations identified seven high-quality CPGs. The median (interquartile range [IQR]) scores for the AGREE II six domains were as follows: scope and purpose, 88.9 % (16.7 %); stakeholder involvement, 84.7 % (34.7 %); rigour of development, 85.4 % (47.9 %); clarity of presentation, 90.3 % (8.3 %); applicability, 77.1 % (40.6 %); and editorial independence, 85.4 % (33.3 %). For AGREE-REX, the domain scores were clinical applicability, 75.0 % (17.0 %); values and preferences, 29.2 % (15.0 %); and implementability, 41.7 % (15.0 %). A total of 148 key recommendations were extracted. Antiplatelet therapy remains contentious for asymptomatic PAD management. Current guidelines increasingly recommend low-dose rivaroxaban (2.5 mg twice daily) plus aspirin for symptomatic PAD, supported by recent cardiovascular outcome trials.

Conclusion: Current PAD guidelines demonstrate variable methodological quality, necessitating improved rigour of development processes and implementation strategies. Future CPGs should strictly adhere to standardized methodologies and prioritize effective dissemination. Different guidelines present varying opinions on antithrombotic treatment strategies. Recommendations should be periodically revised as new evidence becomes available.