Residual risk reduction opportunities in patients with chronic coronary syndrome. Role of dual pathway inhibition

ABSTRACT

Introduction

In this review, the role of the rivaroxaban-plus-aspirin approach (dual pathway inhibition – DPI) in patients with chronic coronary syndrome (CCS) and to perform practical recommendations about its use was updated.

Areas covered

The contents of this review were proposed in an expert meeting. To identify relevant articles, a systematic search of Medline/Embase was performed (to July 2019), using the key words ‘rivaroxaban’, ‘vascular dose’, ‘COMPASS’ and ‘coronary artery disease’ in the search strategy.

Expert opinion

Despite current antithrombotic strategies (single/dual antiplatelet therapy) have decreased rates of recurrent cardiovascular events among patients with CCS, residual risk remains unacceptably high. The COMPASS trial showed in CCS patients that compared with aspirin 100 mg rivaroxaban 2.5 mg bid plus aspirin 100 mg reduced the risk of major cardiac events, cardiovascular hospitalization and mortality, without an increase of intracranial or fatal bleedings. Importantly, residual risk with the rivaroxaban plus aspirin approach was lower than with different dual antiplatelet therapy regimens. The rivaroxaban plus aspirin strategy is of particular benefit in patients with CCS and high-risk cardiovascular feature (i.e. ≥2 vascular beds, heart failure, renal insufficiency, peripheral artery disease, previous stroke or diabetes) and should be considered in these populations.

KEYWORDS:

• COMPASS
• chronic coronary syndrome
• coronary artery disease
• residual risk
• rivaroxaban
• vascular dose

Article highlights

• The current approach of prescribing single antiplatelet therapy in patients with CCS or DAPT during the first year after an acute coronary syndrome and then switching to single therapy, or even remaining on DAPT, seems insufficient to the majority of patients with atherosclerotic CV disease, due to the high risk of recurrent CV events.

• Not only platelet aggregation but also anticoagulation cascade, especially Factor Xa activation, play a key role in line with the pathophysiology of atherothrombosis.

• The COMPASS trial showed in CCS patients that compared with aspirin 100 mg rivaroxaban 2.5 mg bid plus aspirin 100 mg reduced the risk of major cardiac events, cardiovascular hospitalization and mortality, without an increase of intracranial or fatal bleedings.

• Importantly, the net clinical benefit in favor of DPI was consistent, regardless of either the prior history or the time elapsed since the index myocardial infarction.

• The rivaroxaban plus aspirin strategy was of particular benefit in patients with CCS and high-risk cardiovascular feature (i.e. ≥2 vascular beds, heart failure, renal insufficiency, peripheral artery disease, previous stroke or diabetes) and should be considered in these populations.

• In addition, the residual risk of MACE and mortality was lower with the rivaroxaban plus aspirin approach than with the different DAPT strategies.

• Different studies have shown that the COMPASS strategy can be extended to real-life population.

• Different strategies should be developed to implement the COMPASS strategy in clinical practice.

Acknowledgments

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

Declaration or interest

J.R. González-Juanatey reports honoraria for lectures and advisory board from Bayer. M. Almendro-Delia reports consulting fees and/or lectures honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, Eli Lilly, GlaxoSmithKline, Daiichi-Sankyo, Rovi Pharmaceuticals, and Sanofi Aventis, and grants support from AstraZeneca. J. Cosin-Sales reports consulting fees and lectures honoraria from Bayer. S. Bellmunt-Montoya reports consulting fees from Bayer. J.J. Gómez-Doblas reports consulting fees and/or lectures honoraria Bayer, Boehringer Ingelheim, AstraZeneca, Daiichi Sankyo. V. Riambau reports no conflict of interest. J. García-Alegría reports consulting fees and/or lectures honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo. J.L. Hernández has reports honoraria for lectures from AMGEN, MSD, Sanofi, Esteve and Daichii-Sankyo. F.S. Lozano received compensation for advisory-board membership from Boehringer-Ingelheim, Bayer Health Care, Daiichi Sankyo, Rovi and Sanofi-Aventis; and lectures fees from Bayer Health Care, Daiichi Sankyo, Glaxo Smith Kline, Leo Pharma, Menarini, Rovi, and Sanofi-Aventis. C. Suarez Fernández reports consulting fees and lectures honoraria from Bayer.

The authors have no other 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 apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they were the US national leader for COMPASS, have received research support (via PHRI in Canada) from: Bayer, have acted as a consultant for: Bayer and Janssen.

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

Declaration of interest

No potential conflict of interest was reported by the authors.

Additional information

Funding

This paper was funded by Bayer Hispania.