Key result
The addition of new antithrombotic agents to standard care in ACS patients may reduce recurrent vascular events, though bleeding risks vary by drug and patient population.
Why the study?
Does the addition of a third antithrombotic agent to standard care reduce recurrent vascular events in patients with ACS?
Does the addition of a third antithrombotic agent to standard care reduce recurrent vascular events in patients with ACS?
Depending on drug dose and patient population, adding low-dose rivaroxaban to standard antiplatelet therapy may offer a favorable benefit-risk profile for secondary prevention after ACS.
May inform individualized antithrombotic choices in ACS; leaves open optimal regimens and bleeding-risk stratification.
Patients with acute coronary syndrome (ACS) usually receive acetylsalicylic acid plus an adenosine diphosphate (ADP) receptor inhibitor to reduce the long-term risk of recurrent events. However, patients receiving standard antiplatelet prophylaxis still face a substantial risk of recurrent events. Strategies involving 3 antithrombotic agents with different modes of action have now been tested. In Thrombin Receptor Antagonists for Clinical Event Reduction (TRA-CER), compared with standard care alone, bleeding complications including intracranial hemorrhage (ICH) were increased with the addition of vorapaxar, without efficacy benefit. In Trial to Assess the Effects of SCH 530348 in Preventing Heart Attack and Stroke in Patients With Atherosclerosis (TRA 2°P-TIMI 50), the addition of vorapaxar reduced recurrent events compared with standard care in stable patients with prior myocardial infarction. This study was terminated early in patients with prior stroke owing to excess ICH, though an increased risk of ICH or fatal bleeding was not detected in patients with prior myocardial infarction. The Apixaban for Prevention of Acute Ischemic and Safety Events 2 (APPRAISE-2) trial of standard-dose apixaban added to standard care in patients with ACS was also stopped early owing to excess serious bleeding. However, in Rivaroxaban in Combination With Aspirin Alone or With Aspirin and a Thienopyridine in Patients With Acute Coronary Syndromes (ATLAS ACS 2 TIMI 51), fatal bleeding or fatal ICH did not increase with low-dose rivaroxaban added to low-dose acetylsalicylic acid-based standard care compared with standard care alone. In that trial, a significant reduction of recurrent vascular events was shown with 3 antithrombotic regimens compared with standard care. Therefore, depending on drug dose and patient population, further reductions in recurrent vascular events after ACS may be possible in future clinical practice, with a favorable benefit-risk profile.
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Goto et al. (2014) conducted a review in Acute coronary syndrome. New antithrombotics (vorapaxar, apixaban, rivaroxaban) vs. Standard care was evaluated. The addition of new antithrombotic agents to standard care in ACS patients may reduce recurrent vascular events, though bleeding risks vary by drug and patient population.
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