Secondary Prevention with Antithrombotic Therapies in Stable Ischemic Heart Disease Patients: a Review

Stable and unstable ischemic heart disease are a growing component in all facets of healthcare, including ER visits, hospitalizations, and financial costs. With the changing emphasis of healthcare shifting towards the outpatient setting, the onus is on clinicians to appropriately manage such patients to avoid adverse effects and complications. Antithrombotic medications, including aspirin, P2Y₁₂ inhibitors, and rivaroxaban, are currently prescribed or have potential roles in the management of secondary cardiovascular prevention in ischemic heart disease patients. While the majority of studies and findings involve aspirin and clopidogrel, newer oral anticoagulation drugs are arriving, prompting new research to assess their impact on preventing mortality, myocardial infarction, and stroke in such patients.

Aspirin has a well-established history of safety and efficacy in management of secondary cardiovascular protection in ischemic heart disease patients. A dual-antiplatelet regimen, most commonly including aspirin plus clopidogrel, has been documented to be effective as well in achieving the same goals. Newer agents, such as rivaroxaban, are being analyzed to see if there is scope to include these agents for secondary prevention. One recent study, the COMPASS trial, revealed the major concern of these newer medications: while better cardiovascular outcomes were achieved in subjects on aspirin plus rivaroxaban, this was accomplished in the setting of a higher rate of major bleeding events. In conclusion, the evidence thus far has not been significant enough for the American College of Cardiology to recommend the incorporation of oral anticoagulants in the management of stable ischemic heart disease patients, in contrast to aspirin and clopidogrel. As the antithrombotic and antiischemic properties of these newer agents seem evident, so does their potential for increase in risk of bleeding events. Doctors have to individually tailor antithrombotic medication decisions based on the patient's risk-benefit profile.