The "dual-pathway" strategy after acute coronary syndrome: rivaroxaban and antiplatelet agents in the ATLAS ACS 2-TIMI 51 trial.
Bottom Line: Studies with vitamin K antagonists (VKAs) such as warfarin demonstrated a potential to reduce the risk of subsequent death by reinfarction but this benefit was offset by increases in bleeding.Results from studies of two targeted non-VKA OACs also proved disappointing, with little or no apparent reduction in the rate of ischemic events seen.However, the recent ATLAS studies assessing rivaroxaban (an oral factor Xa inhibitor) in patients with ACS demonstrated a reduction in the composite endpoint of deaths from cardiovascular causes, myocardial infarction (MI), or stroke, and a reduction in the rate of stent thrombosis.
Affiliation: Division of Cardiology, Newark Beth Israel Medical Center, Barnabas Health, Newark, NJ, USA; Mount Sinai School of Medicine, New York, NY, USA.Show MeSH
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Mentions: Several meta-analyses of these and similar trials have been conducted [23–25]. Andreotti et al.  identified 14 relevant studies including 25,307 patients with follow-up ranging from 3 months to 5 years (Figure 1). There was no significant advantage of adding VKA (any intensity) to ASA versus ASA alone, in terms of the risk of death (all-cause), nonfatal MI, and nonfatal thromboembolic events (odds ratio [OR] 0.96; 95% confidence interval [CI] 0.90–1.03; P = 0.30). They reported a benefit only when moderate-intensity VKA therapy (target or measured international normalized ratio [INR] 2.0–3.0) was compared with ASA alone (OR 0.73; 95% CI 0.63–0.84; P < 0.0001). However, there was an accompanying increase in the risk of major bleeding events with the combined regimen (OR 1.77; 95% CI 1.47–2.13; P < 0.0001). Testa et al.  extended these results by focusing on studies comparing moderate-intensity VKA plus ASA versus clopidogrel plus ASA. Their analysis included 13 studies with 69,741 patients and concluded that neither regimen offered a benefit over ASA alone with respect to all-cause death, acute MI, thromboembolic stroke, major bleeding, and overall stroke risk.
Affiliation: Division of Cardiology, Newark Beth Israel Medical Center, Barnabas Health, Newark, NJ, USA; Mount Sinai School of Medicine, New York, NY, USA.