Role of rivaroxaban in the prevention of atherosclerotic events

ABSTRACT

Introduction: The current approach of using only antiplatelet therapy for secondary prevention leaves a substantial risk of recurrent cardiovascular complications and mortality.

Areas covered: In this manuscript, the role of coagulation in atherothrombosis is reviewed, as well as the impact of vascular doses of rivaroxaban on major cardiovascular outcomes and major adverse limb events.

Expert opinion: In COMPASS, among patients with coronary heart disease and/or peripheral artery disease, compared to aspirin, the addition of rivaroxaban 2.5 mg twice daily to aspirin, significantly reduced the risk of major atherosclerotic outcomes, cardiovascular death and death for any cause, with a significant increase in the risk of major bleeding, but not fatal or intracranial bleedings. Preclinical data strongly suggest that rivaroxaban exerts vascular protection through different mechanisms, including improvement of endothelial functionality and fibrinolytic activity at endothelium, anti-inflammatory properties, and platelet-dependent thrombin generation. All these data indicate that among patients with atherosclerotic vascular disease, the addition of rivaroxaban 2.5 mg may provide further vascular protection.

KEYWORDS:

• Cardiovascular disease
• coronary artery disease
• peripheral artery disease
• rivaroxaban
• secondary prevention

Article highlights

• The current approach of using only single antiplatelet therapy for secondary prevention in patients with stable coronary artery disease and/or PAD leaves a significant risk of recurrent thrombotic complications.

• The pathophysiology of atherosclerosis is complex and multifactorial, and coagulation plays a key role in atherothrombosis.

• Preclinical data have shown that rivaroxaban exerts vascular protection through different mechanisms, such as improvement of endothelial functionality and fibrinolytic activity at endothelium, anti-inflammatory properties, or platelet-dependent thrombin generation.

• In the COMPASS trial, among patients with coronary heart disease and/or peripheral artery disease, compared to aspirin alone, the addition of rivaroxaban 2.5 mg twice daily to aspirin, significantly reduced the risk of cardiovascular death, stroke, or myocardial infarction by 24%, as well as the risk of cardiovascular death by 22% and death for any cause by 18%, with a significant increase in the risk of major bleeding, but not fatal or intracranial bleedings.

• Particular benefit was obtained among patients with PAD regarding the risk of major adverse limb events, including amputations.

• The antithrombotic approach in patients with stable coronary artery disease and/or PAD should be individualized on the basis of the estimated risk of recurrent ischemic events, MALE and bleeding.

• The addition of rivaroxaban 2.5 mg twice daily to aspirin could be of particular benefit among patients with stable atherosclerotic cardiovascular disease at high risk of major cardiovascular events, but low risk of bleeding.

• Real-life data are warranted to confirm the results of the COMPASS trial in clinical practice.

Declaration of interest

Contents of this review were proposed in an expert meeting. The meeting was sponsored by Bayer Hispania. 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they receive research support from Bayer and Pfizer.

Additional information

Funding

Editorial assistance was provided by Content Ed Net, Madrid, Spain, with funding from Bayer Hispania.