Aspirin and low-dose rivaroxaban – the dual pathway concept in patients with stable atherosclerotic disease: a comprehensive review

ABSTRACT

Introduction

Cardiovascular disease is the leading cause of morbidity and mortality in adults in western nations. In the last decades, tremendous research has been conducted in the field of secondary prevention in order to reduce recurrent cardiovascular events. This review summarizes the novel dual pathway concept of aspirin and very low-dose rivaroxaban, from mechanisms to clinical practice.

Areas covered

The COMPASS trial demonstrated that in patients with stable atherosclerotic disease, very low-dose rivaroxaban, a direct factor Xa inhibitor, when combined with aspirin, reduced the rate of recurrent ischemic events, at the cost of increased bleeding. This effect was present in patients with ischemic heart disease, as well as in patients with atherosclerosis in other beds, such as in peripheral arterial disease. Sub-studies from the COMPASS trial examined other high-risk populations who might benefit the most from this regimen.

Expert opinion

There are currently multiple antiplatelet and anticoagulation treatment regimens for patients with stable atherosclerotic disease. The dual pathway concept is a novel approach that combines both mechanisms. Identifying patients who might benefit the most in terms of ischemic events at the least bleeding events still remains a challenge, yet prescribing this combination to high-risk patients might be the most effective.

KEYWORDS:

• Chronic coronary syndrome
• coronary artery disease
• cardiovascular therapy
• atherosclerotic disease
• rivaroxaban
• secondary prevention
• compass trial
• peripheral artery disease

Article highlights

• Very low dose rivaroxaban and aspirin is a novel approach in the treatment of patients with stable atherosclerotic disease.

• Dual pathway treatment reduces ischemic events in patients with stable atherosclerotic disease, at the cost of increased bleeding, though not fatal bleeds.

• Very low dose rivaroxaban and aspirin is efficient in patients with multiple atherosclerotic beds, such as in patients with chronic coronary syndrome and peripheral artery disease.

• The dual pathway concept has been demonstrated to reduce cardiovascular events in patients with an increased ischemic risk such as patients with diabetes, renal dysfunction, and heart failure.

• Identifying patients who might benefit the most from the dual pathway treatment remains a challenge, though it seems that the net-clinical benefit is higher among patients at increased cardiovascular risk.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript including employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. 

Additional information

Funding

This paper was not funded.