Dual pathway inhibition for atherosclerotic cardiovascular disease: Recent advances

Area of Science:

• Cardiology
• Vascular Medicine
• Pharmacology

Background:

• Atherosclerotic cardiovascular disease (ASCVD) poses a major global health burden, encompassing coronary artery disease (CAD), cerebrovascular disease, and peripheral arterial disease (PAD).
• Antiplatelet therapy has been the standard for preventing ASCVD events, but newer strategies are emerging.
• Dual pathway inhibition (DPI) represents a significant advancement in antithrombotic therapy.

Purpose of the Study:

• To evaluate the benefits and cost-effectiveness of dual pathway inhibition (DPI) in managing acute and chronic atherosclerotic cardiovascular disease (ASCVD).
• To identify patient subgroups within acute coronary syndrome (ACS) and chronic ASCVD populations who derive the greatest benefit from DPI therapy.

Main Methods:

• Randomized trials investigating the efficacy of combining aspirin with low-dose rivaroxaban for antithrombotic therapy.
• Analysis of synergistic effects of aspirin and rivaroxaban on platelet activation and thrombin generation.
• Subgroup analyses to determine absolute benefits in specific patient populations with ACS and chronic ASCVD.

Main Results:

• Dual pathway inhibition (DPI) with aspirin and low-dose rivaroxaban demonstrates synergistic antithrombotic effects, preventing thrombus formation.
• Patients with recent acute coronary syndrome (ACS), positive cardiac biomarkers, STEMI, or heart failure show substantial absolute benefits.
• Patients with chronic ASCVD involving multiple vascular beds, heart failure, CKD, or diabetes also experience significant absolute benefits.

Conclusions:

• Dual pathway inhibition (DPI) is a highly effective strategy for preventing recurrent ASCVD events, particularly in specific high-risk patient groups.
• Ongoing trials are exploring DPI in diverse ASCVD populations, including those with intracranial atherosclerotic disease and peripheral arterial disease.
• Further research is needed to compare rivaroxaban combined with other antiplatelets like clopidogrel or ticagrelor against aspirin-based DPI regimens.