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Rivaroxaban: A Review for Secondary CV Prevention in CAD and PAD
1Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand. demail@springer.com.
Insights
Combining low-dose rivaroxaban with aspirin significantly reduces cardiovascular and limb events in patients with established vascular disease. While major bleeding risk increases, the net clinical benefit favors this dual therapy for high-risk individuals.
Area of Science:
- Cardiovascular Medicine
- Pharmacology
- Clinical Trials
Background:
- Secondary cardiovascular disease (CVD) prevention is critical for patients with vascular conditions like coronary artery disease (CAD) and peripheral artery disease (PAD).
- Managing residual ischemic and bleeding risks in CVD patients on antiplatelet therapy presents a significant clinical challenge.
- Atherosclerosis involves common pathophysiological processes targeted by both anticoagulants and antiplatelets.
Purpose of the Study:
- To evaluate the efficacy and safety of combining rivaroxaban with aspirin for secondary prevention in patients with stable CAD and/or symptomatic PAD.
- To assess the impact of this dual therapy on major adverse cardiovascular events (MACE) and major adverse limb events (MALE).
Main Methods:
- The study involved over 27,000 patients in the global COMPASS trial.
- Participants received either rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily, or aspirin alone.
- Outcomes included major adverse cardiovascular events (MACE), major adverse limb events (MALE), and major bleeding events.
Main Results:
- Rivaroxaban plus aspirin significantly reduced the risk of MACE (myocardial infarction, stroke, CV death) in patients with CAD and/or PAD.
- The combination therapy also significantly reduced the risk of MALE in patients with PAD.
- A significant increase in major bleeding events was observed with rivaroxaban plus aspirin, but not intracranial or fatal bleeding.
Conclusions:
- The dual therapy of rivaroxaban plus aspirin demonstrated a significant net clinical benefit for secondary cardiovascular prevention, outweighing the increased bleeding risk.
- This combination therapy is particularly beneficial for high-risk patients with CAD or symptomatic PAD.
- Rivaroxaban plus aspirin represents an important emerging option for preventing atherothrombotic events in specific patient populations.
Abstract:
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.
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