Rivaroxaban in patients with ischaemic chronic cardiomyopathy and obstructive peripheral arterial disease: rationale for treatment and results

Patients with overt clinical atherosclerosis (ATS) or with previous peripheral vascular events have a high risk of ischaemic complications. A careful control of cardiovascular (CV) risk factors has been shown to improve prognosis, likely driven by a decrease progression of ATS. Prevention of occlusive complications is, on the other hand, based on antithrombotic therapy. So far, this therapeutic goal has been pursued through antiplatelet therapy with aspirin and P2Y12 receptor inhibitors. Anticoagulant therapy with full-dose vitamin K inhibitors, although effective in some arterial conditions, is burdened by high bleeding risk, and by low long-term compliance. In the COMPASS study, the association of aspirin with the factor Xa inhibitor, rivaroxaban, in a dose of one-fourth of the dose used in atrial fibrillation, decreased by more than 20% the incidence of CV events in patients with multi-district ATS. The positive effect was also observed as far as major peripheral complications, the like of critical limb ischaemia or limb amputations. This positive preventive effect was in addition to the effect of other preventive measures, such as the use of statins, ACE inhibitors, and aspirin itself. As compared to the aspirin-only treatment, the association with low-dose rivaroxaban had a significantly higher bleeding risk, which should be carefully considered when evaluating the individual risk/benefit ratio of the combined treatment.