A guide to antiplatelet and statin therapy for patients with peripheral arterial disease, carotid disease, and other conditions caused by plaque build-up in the arteries.
Book a ConsultationIf you have been told you have blocked or narrowed arteries anywhere in your body, it means the lining of those arteries has been affected by a build-up of fatty material called plaque. This usually happens in more than one artery at the same time — including the arteries that supply your heart and brain.
Two types of medicine work together to slow that process down and protect you from a heart attack or stroke. They are not painkillers or a quick fix — they are long-term protection, and they work best when taken every day, reliably, alongside a healthy lifestyle.
Your blood contains platelets — particles which usually clump at sites of injury to stop bleeding. In diseased arteries, platelets can clump together inappropriately and form clots which block blood flow to the heart or brain, causing a heart attack or stroke.
Antiplatelet medicines reduce this clumping tendency. Their main job is to reduce the risk of dangerous clots forming inside your arteries. One of the risks of antiplatelets is increased bruising or bleeding.
When to take it: Once daily, usually in the morning with or after food.
Aspirin has been used for decades to protect people with disease in their arteries. It works by blocking a chemical signal that normally makes platelets sticky and likely to clump together. At 75mg it works very differently from the higher doses used as a painkiller.
Most people tolerate aspirin very well. It can irritate the stomach lining in some people, so it is recommended to be taken with food, in a coated form, or with a tablet that reduces stomach acid. If you notice black or tarry stools, persistent stomach pain, or unusual bruising, tell your doctor.
When to take it: Once daily, can be taken at any time of day.
Clopidogrel works in a slightly different way to aspirin — it blocks a different pathway that platelets use to communicate and helps stop them clumping. It is at least as effective as aspirin for people with disease in the arteries in their legs, and is often preferred.
After certain procedures to improve blood supply, your specialist may prescribe both aspirin and clopidogrel together for a period of time. This is called dual antiplatelet therapy (DAPT), and is more intensive to protect the treated artery while it heals. Your team will tell you exactly how long to continue both.
Statins lower the amount of cholesterol in your blood — specifically the LDL cholesterol, often called the "bad" cholesterol. High LDL cholesterol contributes to the build-up of plaque in the walls of your arteries.
Statins also help stabilise any disease in your arteries, making the plaque surface less likely to crack or rupture. A ruptured plaque is the most common trigger for a heart attack or stroke.
For people with established disease in their arteries, a high-intensity statin is usually recommended by clinical guidelines.
When to take it: Once daily, usually at night.
Atorvastatin at 80mg is the most commonly prescribed statin for people with arterial disease. It is a high-intensity statin, producing a large reduction in LDL cholesterol — usually more than 50%. Taking it at night is often recommended because the liver produces more cholesterol overnight, but it works well at any time of day as long as it is taken consistently.
Your doctor will usually check that your LDL cholesterol has fallen and is within the target range. Guidelines often recommend LDL to be below 1.8 mmol/L, and sometimes below 1.4 mmol/L in very-high-risk patients.
When to take it: Once daily.
Rosuvastatin is equally effective and sometimes used when atorvastatin causes side effects, as it is better tolerated in some patients. Both statins produce a similar reduction in LDL level. If you have been switched from one to the other, the clinical reason is usually improved tolerability — the protection is the same.
The most common concern patients raise about statins is muscle pain. Serious statin-related muscle injury is rare, while milder aching is more common and often improves after dose adjustment or switching treatment.
If you develop significant muscle pain, weakness, or dark-coloured urine while taking a statin, contact your GP to review the medication.
Your GP will do blood tests to check whether your medicines are working. The main value to check is your LDL cholesterol level. In people with vascular disease, the target is now lower than it used to be:
Best medical therapy (BMT) in patients with arterial disease — including peripheral arterial disease (PAD), carotid artery disease, and aortic pathology — refers to evidence-based pharmacological and lifestyle interventions aimed at reducing cardiovascular risk and disease progression. These typically include antiplatelet therapy, high-intensity statin therapy, blood pressure optimisation, lifestyle modification, and glycaemic optimisation in diabetics. This page covers antiplatelet and statin therapy in detail, with current guideline-aligned targets and prescribing reference.
Single antiplatelet therapy (SAPT) is recommended in symptomatic PAD to reduce major adverse cardiovascular events (MACE). Clopidogrel and aspirin are both acceptable options; contemporary vascular guidance often favours clopidogrel, while ACC/AHA guidance accepts either for symptomatic PAD.
Preferred in symptomatic PAD per ESC guidelines
Acceptable alternative; preferred if aspirin-only indication
Specific indications — to be guided by specialist
Vascular dose rivaroxaban for selected patients
| Scenario | Recommended approach | Duration / note |
|---|---|---|
| Asymptomatic PAD (ABI <0.9) | SAPT may be reasonable in selected patients after weighing bleeding risk | Individualise |
| Symptomatic PAD (claudication) | Clopidogrel 75mg OD or aspirin 75–100mg OD | Long term |
| CLTI | SAPT is standard; rivaroxaban 2.5mg BD + aspirin may be appropriate in selected patients without high bleeding risk | Review regularly |
| After peripheral angioplasty without stent | Follow procedural plan; SAPT is common long term | Individualise |
| After peripheral stenting | DAPT (usually aspirin + clopidogrel) | Usually 1–3 months, then SAPT |
| After lower extremity revascularisation | Rivaroxaban 2.5mg BD + aspirin 75–100mg OD should be considered in suitable patients | Continue with periodic reassessment of bleeding risk |
| Stable symptomatic PAD | SAPT or consider rivaroxaban 2.5mg BD + aspirin in selected higher-risk patients | Long term if benefit outweighs bleeding risk |
| After carotid endarterectomy | Aspirin or clopidogrel monotherapy | Long term |
| After carotid artery stenting | DAPT (aspirin + clopidogrel), then SAPT | At least 4 weeks post-stenting, then monotherapy |
| After peripheral bypass | Follow surgeon's discharge plan; aspirin-based therapy is common | Individualise by conduit, indication, and bleeding risk |
High-intensity statin therapy is recommended in patients with established atherosclerotic cardiovascular disease (ASCVD), including PAD. A ≥50% LDL-C reduction from baseline is a core treatment goal. Exact lipid targets should be labelled by guideline source: NICE uses a UK secondary-prevention framework, whereas ESC 2019 and ACC/AHA 2026 use lower LDL thresholds in high-risk and very-high-risk patients.
| Statin | Dose | Intensity | LDL-C reduction | Key notes |
|---|---|---|---|---|
| Atorvastatin | 80mg OD | High | ~55–60% | First-line in PAD/ASCVD. CYP3A4 metabolised — check interactions. Grapefruit juice interaction. |
| Atorvastatin | 40mg OD | High | ~49% | Use if 80mg not tolerated. Still high-intensity per ACC/AHA. |
| Rosuvastatin | 40mg OD | High | ~55–60% | Not a CYP3A4 substrate — fewer drug interactions. Preferred in patients on CYP3A4 inhibitors. |
| Rosuvastatin | 20mg OD | High | ~48% | Acceptable high-intensity option. Renal dosing: max 20mg if eGFR <30. |
| Simvastatin | 40mg OD | Moderate | ~35% | Not first-line in ASCVD — insufficient LDL-C reduction. Avoid 80mg (myopathy risk). |
| Pravastatin | 40–80mg OD | Moderate | ~30–40% | Lowest myopathy risk — used in patients with statin intolerance. |
Use this table by source. NICE remains the key UK reference for day-to-day secondary prevention; ESC 2019 and ACC/AHA 2026 provide lower LDL-C thresholds for high-risk and very-high-risk ASCVD.
| Framework | Target | How to use it |
|---|---|---|
| NICE NG238 (UK secondary prevention) | LDL-C ≤2.0 mmol/L or non-HDL-C ≤2.6 mmol/L | Routine UK follow-up and audit in secondary prevention |
| ESC/EAS 2019 — high risk | LDL-C <1.8 mmol/L and ≥50% LDL-C reduction | High-risk ASCVD patients |
| ESC/EAS 2019 — very high risk | LDL-C <1.4 mmol/L and ≥50% LDL-C reduction | Very-high-risk ASCVD, including many PAD patients with multiple risk features |
| ACC/AHA 2026 — ASCVD not very high risk | LDL-C <70 mg/dL (<1.8 mmol/L) | International target framework for clinical ASCVD |
| ACC/AHA 2026 — very high risk ASCVD | LDL-C <55 mg/dL (<1.4 mmol/L) | International target framework for very-high-risk ASCVD |
| Test | Timing | Action |
|---|---|---|
| Lipid profile | Baseline; 2–3 months after starting or changing treatment; at least annually once stable | Assess % LDL-C reduction and whether at target; intensify therapy if needed |
| LFTs (ALT/AST) | Baseline and ~2–3 months; later only if clinically indicated | If transaminases rise and persist at >3× ULN, stop the statin and reassess |
| CK | Not routinely required; check if muscle symptoms develop or if baseline risk is high | If markedly elevated, withhold statin and assess for myopathy/rhabdomyolysis |
| HbA1c / fasting glucose | According to the patient's diabetes or metabolic-risk profile | Do not withhold statins in ASCVD because of diabetes risk |
| eGFR | Baseline, then annually | Do not prescribe rosuvastatin if eGFR <30; aspirin bleeding risk increased if eGFR <15 |
| Parameter | Target / principle | Reference frame |
|---|---|---|
| LDL-C reduction | ≥50% reduction from baseline in ASCVD | ACC/AHA 2024 PAD; ESC 2019 |
| UK lipid audit target | LDL-C ≤2.0 mmol/L or non-HDL-C ≤2.6 mmol/L | NICE NG238 |
| Intensive LDL-C target | <1.8 mmol/L (high risk); <1.4 mmol/L (very high risk) | ESC 2019; ACC/AHA 2026 |
| Blood pressure | Commonly aim <130/80 mmHg in PAD where appropriate | ACC/AHA 2024 PAD |
| Diabetes management | Optimise glycaemic control and use cardioprotective therapy where indicated | NICE / ACC/AHA guidance |
| Lp(a) | Measure at least once in all patients | ACC/AHA 2026 |
| Smoking cessation | Complete abstinence — one of the most important risk modifiers | All major vascular guidelines |
| Exercise | Structured or supervised exercise recommended for claudication when available | ACC/AHA 2024 PAD |