Deepak Bhatt, MD: Implementing Rivaroxaban Use for PAD/CAD

After the release of results from the COMPASS trial, cardiologists and physicians across the nation now had knowledge of, and access to, a treatment for patients with peripheral, coronary, or polyvascular artery disease.

With results showcasing the overwhelming efficacy of combination 2.5 mg rivaroxaban (Xarelto) twice-daily with 100 mg aspirin once daily, physicians across a slew of specialties regarded the trial as practice-changing. Yet, while effective patients are key to treating conditions like peripheral arterial disease (PAD) and coronary artery disease (CAD), initiating new therapies into a patient’s current treatment regimen can sometimes be a challenge.

While study results reflected reductions in both major adverse cardiovascular and major adverse limb events, patients in the rivaroxaban-plus-aspirin treatment group experienced an increase risk of major bleeding. With this knowledge in mind, cardiologists have multiple factors to consider when deciding to switch a patient to this new treatment regimen.

COMPASS investigator Deepak Bhatt, MD, MPH, executive director of Interventional Cardiovascular Programs at Brigham and Women's Hospital and professor of medicine at Harvard Medical School, recently sat down with MD Magazine® to discuss how use of rivaroxaban-plus-aspirin fits into a patient’s already established treatment algorithm.

MD Mag: How does rivaroxaban fit into a patient’s pre-established treatment algorithm?

Bhatt: The COMPASS trial was a very positive trial with implications that are quite broad, because the results are apply to a lot of patients. Really, it applies to patients with stable CAD and PAD that are at high ischemic risk and low bleeding risk. We studied in the REACH registry which patients with stable CAD might be eligible, and half the patients we found were eligible for COMPASS and about two-thirds of patients with PAD.

So, that's a lot of patients that are eligible. But practically speaking, it's not an easy thing for a busy physician in a 7-10 minute encounter to see a stable patient might be at high risk, but a stable outcome patient who is not complaining of anything, and then starting them on an anticoagulant—albeit, a reduced dose—an agent that may cause bleeding, an agent that has cost associated with it. That's not an easy thing to do.

So, I think in terms of treatment algorithms, it probably makes sense to identify patients that really are at the highest end of the ischemic risk spectrum, such as those with polyvascular disease—concomitant CAD and PAD for example, where you know that plaque burden is quite high and we know from a number of studies, such as the REACH registry, that their risk of future ischemic events is also quite high. So, in such patients—assuming they're at low risk of bleeding and have had no bleeding complications while on aspirin—I think intensifying their regimen by adding 2.5 mg twice a day rivaroxaban may make sense.