Key result
Rivaroxaban plus aspirin reduced total arterial and venous thrombotic events compared to aspirin alone after lower extremity revascularization (7.9 vs 10.3 events/100 pt-years; HR 0.77; p=0.0005).
Why the study?
Vascular disease burden after lower extremity revascularization extends beyond first events and local vascular beds, but the total arterial and venous thrombotic burden and the effect of dual pathway inhibition were not fully assessed.
Does rivaroxaban 2.5 mg twice-daily added to aspirin reduce total arterial and venous thrombotic events in symptomatic PAD patients undergoing lower extremity revascularization?
RCT (n=6,564)
randomized
Does rivaroxaban 2.5 mg twice-daily added to aspirin reduce total arterial and venous thrombotic events in symptomatic PAD patients undergoing lower extremity revascularization?
Hazard Ratio: 0.77 (95% CI 0.67–0.89)
Absolute Event Rate: 7.9% vs 10.3%
p-value: p=.0005
In symptomatic PAD patients undergoing lower extremity revascularization, adding low-dose rivaroxaban to aspirin significantly reduces the total burden of arterial and venous thrombotic events compared to aspirin alone.
Supports adding low-dose rivaroxaban to aspirin after PAD revascularization; extends prior evidence to total arterial and venous events.
BACKGROUND: Vascular disease burden after lower extremity revascularization (LER) comprises more than the first event, more vascular beds than the local arteries, and more than one clinical event type. OBJECTIVES: Assess total arterial and venous thrombotic burden after LER for symptomatic peripheral artery disease (PAD) and effect of low-dose anticoagulation added to low-dose antiplatelet therapy. PATIENTS/METHODS: VOYAGER PAD randomized 6564 symptomatic PAD patients undergoing LER to rivaroxaban 2.5 mg twice-daily or placebo on aspirin background. Marginal proportional-hazards models used to generate treatment hazard ratios and associated 95% CIs for first and total events; non-thrombotic deaths treated as competing terminal events. Incidence rates calculated as number of events per 100 patient-years follow-up. RESULTS: Over 2.5 years (median), first and total thrombotic event rates: 7.1 and 10.3 events/100 patient-years, respectively, in placebo group. Two-thirds (925/1372) of total thrombotic events (arterial 95%, venous 5%) were nonfatal first events. Nearly one-third of patients with first event had a second arterial or venous thrombotic event. Rivaroxaban plus aspirin reduced first and total arterial and venous thrombotic events to 5.4 and 7.9 events/100 patient-years, respectively, a reduction in total thrombotic events over aspirin of 23% (HR: 0.77, 95%CI: 0.67-0.89, p = .0005), preventing 6.1 total arterial and venous thrombotic events at 3 years. CONCLUSIONS: Assessing total arterial and venous thrombotic events, not just first events, provides more complete information about disease burden and absolute on-treatment impact. Following LER, judicious modulation of more than one coagulation pathway can provide broader benefit than intensifying inhibition of one hemostatic system component.
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Berkowitz et al. (2022) conducted an RCT in symptomatic peripheral artery disease (PAD) (n=6,564). Rivaroxaban vs. Placebo on aspirin background was evaluated on Total arterial and venous thrombotic events (HR 0.77, 95% CI 0.67-0.89, p=.0005). Rivaroxaban plus aspirin reduced total arterial and venous thrombotic events compared to aspirin alone after lower extremity revascularization (7.9 vs 10.3 events/100 pt-years; HR 0.77; p=0.0005).
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