Drugs. 2020 Sep 10. doi: 10.1007/s40265-020-01397-7. Online ahead of print.
Secondary cardiovascular (CV) prevention in patients with vascular disease [e.g. coronary (CAD) and peripheral (PAD) artery disease] is crucial and typically involves antiplatelet therapy with aspirin; however, managing residual ischaemic and bleeding risks in CV disease (CVD) remains a challenge. Combining the oral anticoagulant rivaroxaban (Xarelto®) with aspirin targets both the platelet and thrombotic processes of atherosclerosis, a common pathophysiological process associated with CVD. In the global COMPASS trial (n > 27,000), rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily (vs aspirin alone) significantly reduced the risk of the primary composite major adverse CV event (MACE) outcome (i.e. myocardial infarction, stroke or CV death) in adults with stable CAD and/or PAD and, in those with PAD, significantly reduced the risk of the composite major adverse limb event (MALE) outcome. Rivaroxaban + aspirin treatment was generally well tolerated; however, the risk of the composite major bleeding outcome, but not intracranial or fatal bleeding, was significantly higher with rivaroxaban + aspirin than aspirin. The increased risk for the composite major bleeding outcome did not negate the composite net clinical benefits of rivaroxaban + aspirin for secondary CV prevention, with rivaroxaban + aspirin especially beneficial in those with a greater CV risk at baseline. Ongoing clinical experience is required to fully define the role of rivaroxaban + aspirin in secondary CV prevention. In the meantime, dual therapy with rivaroxaban + aspirin is an important emerging option for secondary CV prevention of atherothrombotic events in adults with CAD or symptomatic PAD who are at high risk of ischaemic events.