Eligibility and Implementation of Rivaroxaban for Secondary Prevention of Atherothrombosis in Clinical Practice-Insights From the CANHEART Study

• Published in: Journal of the American Heart Association 2022-12, Vol.11 (24), p.e026553
• Main Authors: Sheth, Maya S, Yu, Bing, Chu, Anna, Porter, Joan, Tam, Derrick Y, Ferreira-Legere, Laura E, Goodman, Shaun G, Farkouh, Michael E, Ko, Dennis T, Abdel-Qadir, Husam, Udell, Jacob A
• Format: Article
• Language: English
• Subjects: Aspirin - therapeutic use; coronary artery disease; Coronary Artery Disease - chemically induced; Coronary Artery Disease - drug therapy; Drug Therapy, Combination; Factor Xa Inhibitors - adverse effects; Hemorrhage - chemically induced; Hemorrhage - epidemiology; Humans; Original Research; Peripheral Arterial Disease - diagnosis; Peripheral Arterial Disease - drug therapy; Peripheral Arterial Disease - epidemiology; peripheral artery disease; Platelet Aggregation Inhibitors - adverse effects; rivaroxaban; Rivaroxaban - adverse effects; Secondary Prevention
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.122.026553

Background The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial decreased major adverse cardiovascular events with very low-dose rivaroxaban and aspirin in patients with coronary artery disease and peripheral artery disease. We examined the eligibility and potential real-world impact of this strategy on the COMPASS-eligible population. Methods and Results COMPASS eligibility criteria were applied to the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) registry, a population-based cohort of Ontario adults. We compared 5-year major adverse cardiovascular events and major bleeding rates stratified by COMPASS eligibility and by clinical risk factors. We applied COMPASS trial rivaroxaban/aspirin arm hazard ratios to estimate the potential impact on the COMPASS-eligible cohort. Among 362 797 patients with coronary artery disease or peripheral artery disease, 38% were deemed eligible, 47% ineligible, and 15% indeterminate. Among eligible patients, a greater number of risk factors was associated with higher rates of cardiovascular outcomes, whereas bleeding rates increased minimally. Over 5 years, applying COMPASS treatment effects to eligible patients resulted in a 2.4% absolute risk reduction of major adverse cardiovascular events and a number needed to treat of 42, and a 1.3% absolute risk increase of major bleeding and number needed to harm (NNH) of 77. Those with at least 2 risk factors had a 3.0% absolute risk reduction of major adverse cardiovascular events (number needed to treat =34) and a 1.6% absolute risk increase of major bleeding (number needed to harm =61). Conclusions Implementation of very-low-dose rivaroxaban therapy would potentially impact 2 in 5 patients with atherosclerotic disease in Ontario. Eligible individuals with 2 comorbidities represent a high-risk subgroup that may derive the greatest benefit-to-risk ratio. Selection of patients with high-risk predisposing factors appears appropriate in routine practice.