Improving medical adherence and antithrombotic management for patients with chronic limb threatening ischaemia in Singapore LETTER TO THE EDITOR Dear Editor, Chronic limb threatening ischaemia (CLTI) represents the most advanced stage of peripheral artery disease (PAD), which, if left untreated, can progress to ulceration, gangrene, sepsis, major lower extremity amputation (LEA) and premature death. The prevalence of PAD ranges from 3% to 10% in the general population, increasing to 15-20% in

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... ople aged ≥70 years. According to the 2015 report by the Organization for Economic Co-operation and Development, 1 major LEA rates in Singapore are 2-3 times higher than those in Western countries, and are in fact the highest in the world. In Singapore, PAD patients are predominantly diabetic compared to PAD patients in Western populations (diabetes mellitus type 2, 90% versus 50%), younger at onset (50 vs 60 years), present with minimal claudication symptoms, and largely belowknee atherosclerotic occlusions (vs aorto-iliac-femoral disease), and more likely to have chronic renal failure (50% vs 27%). 2 The 1-year risk of major LEA in patients with CLTI exceeds 15-20% and the 5-year all-cause mortality rate is approximately 50%. 3 As they have significant systemic atherosclerosis, patients with CLTI are at increased risk of premature death and have a higher incidence of cardiovascular (CV) events. 4 Therefore, with a heightened risk of global atherothrombosis, systemic vascular prevention strategies are essential for the best holistic treatment. Current guidelines recommend antiplatelet monotherapy for prevention of CV events with a class IA recommendation for aspirin or clopidogrel, based on results of large CV outcome trials. In contrast, dual antiplatelet therapy combining aspirin and clopidogrel is used after interventionregardless of surgical or endovascular revascularisation for the reduction of post-procedural complications. It was given a class IIa, level C recommendation in the absence of any randomised data to support this indication. 5 A recent rapid review in the Annals by our group suggested adherence to evidence-based medical treatment is extremely variable and that undertreatment is common in the PAD setting. 6 Furthermore, data from Asian countries on this front are lacking. Our institution, the Singapore General Hospital, a tertiary vascular centre that performs over 900