Key result
Low-dose rivaroxaban plus aspirin cuts MACE ~24% vs aspirin alone in chronic CAD and PAD.
Why the study?
Patients with vascular diseases remain at high risk for recurrent ischemic events despite guideline-based therapies, requiring novel therapeutic strategies to reduce residual risk.
Does dual pathway inhibition with low-dose rivaroxaban plus aspirin reduce recurrent ischemic events in outpatients with cardiovascular disease?
Does dual pathway inhibition with low-dose rivaroxaban plus aspirin reduce recurrent ischemic events in outpatients with cardiovascular disease?
Hazard Ratio: 0.76 (95% CI 0.66–0.8)
Absolute Event Rate: 4.1% vs 5.4%
p-value: p=0.001
Low-dose rivaroxaban combined with aspirin provides a significant reduction in ischemic events for patients with chronic CAD and PAD, and is recommended by current guidelines for high-risk patients despite an increased risk of non-fatal bleeding.
Supports dual pathway inhibition for residual ischemic risk in vascular disease; confirms COMPASS benefits and extends antithrombotic options beyond antiplatelet monotherapy.
Despite availability of effective preventive therapies based on guidelines, patients with vascular diseases continue to be at a high risk for recurrent ischemic events. Therefore, novel therapeutic strategies are required to further reduce the residual risk present in these patients. Platelet aggregation and fibrin organization are involved in arterial thrombosis. Rivaroxaban is capable of targeting both processes and has a synergistic effect when used in combination with acetylsalicylic acid (ASA), providing the so‑called dual pathway inhibition (DPI). The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial showed that the DPI (a combination of rivaroxaban at 2.5 mg twice daily [vascular dose] and ASA at 100 mg once daily) reduced cardiovascular death, stroke, or myocardial infarction by 24% in patients with chronic coronary artery disease (CAD) and peripheral artery disease (PAD). Subsequently, the VOYAGER PAD (Vascular Outcomes Study of ASA Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) trial confirmed the effectiveness of the vascular dose of rivaroxaban in patients with PAD after lower‑extremity revascularization, as compared with ASA alone. Therefore, DPI is recommended in the patients with CAD (+/- PAD) or symptomatic PAD at a high risk of ischemia. The purpose of this review is to examine the clinical benefits and practical implications of DPI in the CAD and PAD patients.
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Leonardo De Luca (2023) conducted a review in Cardiovascular disease (coronary artery disease and peripheral artery disease). Low-dose rivaroxaban plus aspirin vs. Aspirin alone was evaluated on Composite of cardiovascular mortality, stroke, and myocardial infarction (COMPASS trial) (HR 0.76, 95% CI 0.66-0.8, p=0.001). Dual pathway inhibition with low-dose rivaroxaban and aspirin reduced the composite of cardiovascular mortality, stroke, or myocardial infarction by 24% compared to aspirin alone in patients with chronic coronary and peripheral artery disease.
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