Atherosclerotic cardiovascular disease (ASCVD), characterized by the buildup of arterial plaque, is a leading cause of illness and death worldwide. This patient population faces a risk of recurrent major adverse cardiovascular events, underscoring the need for optimal secondary prevention strategies. One such strategy is dual pathway inhibition (DPI) therapy, which combines aspirin with rivaroxaban to simultaneously target the two main pathways of blood clot formation (thrombus).
The COMPASS trial established the efficacy of DPI therapy, demonstrating a significant reduction in the absolute risk of major cardiovascular events with acceptable safety regarding major bleeding. To address the limited generalizability of clinical trials and their typically lower-risk cohorts, the XATOA registry validated DPI in a real-world setting, with a particular focus on the high-risk subgroup of patients with concurrent ASCVD and heart failure (HF). This analysis tracked the clinical outcomes of over 5,532 patients (4,022 with documented HF status), measuring a composite primary endpoint of cardiovascular death, myocardial infarction, or stroke, and monitoring major bleeding as the key safety outcome.
Over a median follow-up of 465 days, the primary endpoint was higher in patients with heart failure (4.9%) compared to those without (2.4%). Notably, the rate of major bleeding was virtually identical between the two groups (0.9% vs 1.11%). These real-world findings from the XATOA registry confirm that even in a high-risk group of patients living with both ASCVD and HF, DPI therapy maintains an acceptable safety profile with clinical event rates consistent with established randomized controlled trials. Consequently, this cumulative evidence strongly supports DPI therapy as a critical and feasible secondary prevention strategy for this vulnerable patient population.
This research was led by Pishoy Gouda, MB BCh BAO, MSc, and co-authored by fellow CVC members Robert Welsh, MD and Justin Ezekowitz, MBBCh, MSc, together with Alain Gay, MD and Kai Vogtländer, MSc (Bayer AG), Victor Aboyans, MD, PhD (Dupuytren University Hospital), Sebastian Debus, MD (University of Hamburg-Eppendorf), Keith Fox, MB, ChB (University of Edinburgh) and Uwe Zeymer, MD (Institut für Herzinfarktforschung).
