open access

Vol 80, No 12 (2022)
Review paper
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Dual pathway inhibition for atherosclerotic cardiovascular disease: Recent advances

Stephanie Carlin1, Tim A.C. de Vries234, Andrzej Budaj5, John Eikelboom6
DOI: 10.33963/KP.a2022.0283
·
Pubmed: 36601884
·
Kardiol Pol 2022;80(12):1200-1210.
Affiliations
  1. Thrombosis Service, Hamilton General Hospital, Hamilton, Ontario, Canada
  2. Heart Center, Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
  3. Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands
  4. Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
  5. Department of Cardiology, Center of Postgraduate Medical Education, Grochowski Hospital, Warszawa, Poland
  6. Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada

open access

Vol 80, No 12 (2022)
Review article

Abstract

Atherosclerotic cardiovascular disease (ASCVD), which includes coronary artery disease (CAD), cerebrovascular disease, and peripheral arterial disease (PAD) is associated with significant morbidity, mortality, and healthcare costs. Antiplatelet therapy has long been the mainstay of antithrombotic therapy for the prevention of first-ever and recurrent ASCVD events. More recently, however, randomized trials have demonstrated the benefits and cost-effectiveness of a dual pathway inhibition (DPI) strategy in acute and chronic ASCVD. When used in combination, aspirin and low-dose rivaroxaban work synergistically to inhibit platelet activation and thrombin generation, thereby preventing thrombus formation. Among patients with recent acute coronary syndrome (ACS), those with positive cardiac biomarkers or ST-segment elevation myocardial infarction, or a history of heart failure derive the greatest absolute benefits. Among patients with chronic ASCVD, those with involvement of two or more vascular beds, heart failure, chronic kidney disease, or diabetes derive the greatest absolute benefits. Additional trials are underway to assess the impact of DPI therapy in other populations of interest, including patients with ACS at high risk of left ventricular thrombus formation, intracranial atherosclerotic disease with recent transient ischemic attack or stroke, peripheral arterial disease with limiting claudication or post lower extremity revascularization, and advanced chronic kidney disease with ASCVD or risk factors for ASCVD. Further work is required to assess the possible added benefit of combining rivaroxaban with clopidogrel or ticagrelor instead of aspirin.

Abstract

Atherosclerotic cardiovascular disease (ASCVD), which includes coronary artery disease (CAD), cerebrovascular disease, and peripheral arterial disease (PAD) is associated with significant morbidity, mortality, and healthcare costs. Antiplatelet therapy has long been the mainstay of antithrombotic therapy for the prevention of first-ever and recurrent ASCVD events. More recently, however, randomized trials have demonstrated the benefits and cost-effectiveness of a dual pathway inhibition (DPI) strategy in acute and chronic ASCVD. When used in combination, aspirin and low-dose rivaroxaban work synergistically to inhibit platelet activation and thrombin generation, thereby preventing thrombus formation. Among patients with recent acute coronary syndrome (ACS), those with positive cardiac biomarkers or ST-segment elevation myocardial infarction, or a history of heart failure derive the greatest absolute benefits. Among patients with chronic ASCVD, those with involvement of two or more vascular beds, heart failure, chronic kidney disease, or diabetes derive the greatest absolute benefits. Additional trials are underway to assess the impact of DPI therapy in other populations of interest, including patients with ACS at high risk of left ventricular thrombus formation, intracranial atherosclerotic disease with recent transient ischemic attack or stroke, peripheral arterial disease with limiting claudication or post lower extremity revascularization, and advanced chronic kidney disease with ASCVD or risk factors for ASCVD. Further work is required to assess the possible added benefit of combining rivaroxaban with clopidogrel or ticagrelor instead of aspirin.

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Keywords

atherosclerosis, cerebrovascular disease, coronary artery disease, peripheral arterial disease, rivaroxaban

About this article
Title

Dual pathway inhibition for atherosclerotic cardiovascular disease: Recent advances

Journal

Kardiologia Polska (Polish Heart Journal)

Issue

Vol 80, No 12 (2022)

Article type

Review paper

Pages

1200-1210

Page views

568

Article views/downloads

143

DOI

10.33963/KP.a2022.0283

Pubmed

36601884

Bibliographic record

Kardiol Pol 2022;80(12):1200-1210.

Keywords

atherosclerosis
cerebrovascular disease
coronary artery disease
peripheral arterial disease
rivaroxaban

Authors

Stephanie Carlin
Tim A.C. de Vries
Andrzej Budaj
John Eikelboom

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