Cost-effectiveness of rivaroxaban plus aspirin (dual pathway inhibition) for prevention of ischaemic events in patients with cardiovascular disease: on top optimisation of secondary prevention medication in the context of COVID-19 pandemia

AbstractThe optimal anti-thrombotic therapy for secondary prevention after an acute coronary syndrome is still a matter of debate. While current guidelines recommend dual anti-platelet therapy with aspirin and a P2Y12 inhibitor over 12 months especially in patients with stent implantation, the value of prolonged anticoagulation is still controversial. In the ATLAS-TIMI 52 trial, a low-dose direct factor Xa inhibition with rivaroxaban compared with placebo reduced the combined primary endpoint of cardiovascular mortality, myocardial infraction and stroke with an increase in major bleeding complications. This article discusses the value and problems of adding low-dose rivaroxaban to anti-platelet therapy as secondary prevention measure after an acute myocardial infarction. It will describe the pros and cons of intensified anti-platelet therapy versus dual pathway inhibition and give recommendations for different patient groups in clinical practice.

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The Cost-Effectiveness of Exercise Training for the Primary and Secondary Prevention of Cardiovascular Disease

Journal of Cardiopulmonary Rehabilitation ◽

10.1097/00008483-200005000-00002 ◽

2000 ◽

Vol 20 (3) ◽

pp. 147-155 ◽

Cited By ~ 46

Author(s):

Ilka Lowensteyn ◽

Louis Coupal ◽

Hanna Zowall ◽

Steven A. Grover

Keyword(s):

Cardiovascular Disease ◽

Cost Effectiveness ◽

Exercise Training ◽

Secondary Prevention ◽

Primary And Secondary Prevention ◽

The Cost ◽

Prevention Of Cardiovascular Disease

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Dual Pathway Inhibition for Vascular Protection in Patients with Atherosclerotic Disease: Rationale and Review of the Evidence

Thrombosis and Haemostasis ◽

10.1055/s-0040-1713376 ◽

2020 ◽

Vol 120 (08) ◽

pp. 1147-1158 ◽

Cited By ~ 4

Author(s):

Jeffrey Ian Weitz ◽

Dominick J. Angiolillo ◽

Tobias Geisler ◽

Stefan Heitmeier

Keyword(s):

Secondary Prevention ◽

Antiplatelet Therapy ◽

Standard Of Care ◽

Atherosclerotic Disease ◽

Vascular Protection ◽

Coronary Syndrome ◽

Plaque Disruption ◽

Dual Pathway ◽

Artery Disease ◽

Pathway Inhibition

AbstractDespite advances in secondary prevention strategies in patients with cardiovascular disease, the residual risk of recurrent atherothrombotic events remains high. Dual-antiplatelet therapy is the standard of care for secondary prevention in patients with acute coronary syndrome (ACS), whereas single antiplatelet therapy, generally with aspirin, is the standard of care for secondary prevention in stable patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease. However, atherosclerotic plaque disruption not only triggers platelet activation but also results in thrombin generation because of tissue factor exposure. Therefore, blocking both pathways by combining antiplatelet therapy with an anticoagulant, or dual pathway inhibition (DPI), has the potential to be more effective than inhibiting either pathway alone. The benefit of DPI has been demonstrated in the ATLAS ACS 2-TIMI 51, COMPASS, and VOYAGER PAD trials, where the combination of rivaroxaban vascular dose (2.5 mg twice daily) plus aspirin significantly reduced the risk of atherothrombotic events compared with aspirin across a broad range of patients, including those with recent ACS, those with chronic CAD and/or PAD, and patients with PAD who have undergone peripheral revascularization. This article provides the rationale for this regimen in more detail, including why the DPI regimen with the rivaroxaban vascular dose was developed for vascular protection in a broad spectrum of patients with atherosclerotic disease.

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Rivaroxaban plus aspirin for the prevention of ischaemic events in patients with cardiovascular disease: a cost-effectiveness study

European Journal of Preventive Cardiology ◽

10.1177/2047487320913380 ◽

2020 ◽

Vol 27 (13) ◽

pp. 1354-1365 ◽

Cited By ~ 2

Author(s):

Svenja Petersohn ◽

Xavier Pouwels ◽

Bram Ramaekers ◽

Arina ten Cate-Hoek ◽

Manuela Joore

Keyword(s):

Coronary Artery Disease ◽

Cost Effectiveness ◽

Coronary Artery ◽

Peripheral Arterial Disease ◽

Antiplatelet Therapy ◽

Arterial Disease ◽

Dual Pathway ◽

Artery Disease ◽

Pathway Inhibition ◽

Peripheral Arterial

Background Dual pathway inhibition with 2.5 mg rivaroxaban twice daily plus 100 mg aspirin once daily may be a promising alternative to 100 mg aspirin antiplatelet therapy for the prevention of cardiovascular events in patients with coronary artery disease and/or peripheral arterial disease. However, treatment costs and bleeding risks are higher, and there is another treatment option for peripheral arterial disease, 75 mg clopidogrel. A comprehensive assessment of benefits, risks and costs of dual pathway inhibition versus standard of care is needed. Methods We used a state transition model including cardiovascular, ischaemic limb and bleeding events to compare dual pathway inhibition to aspirin antiplatelet therapy in coronary artery disease, and additionally to clopidogrel antiplatelet therapy in peripheral arterial disease patients. We calculated the incremental cost-effectiveness ratio from costs and quality-adjusted life-years of lifelong treatment, and the cost-effectiveness probability at a €50,000/quality-adjusted life-year threshold. Results Quality-adjusted life-years and costs of dual pathway inhibition were highest, the incremental cost-effectiveness ratios versus aspirin were €32,109 in coronary artery disease and €26,381 in peripheral arterial disease patients, with 92% and 56% cost-effectiveness probability, respectively (clopidogrel was extendedly dominated). Incremental cost-effectiveness ratios were below €20,000 in comorbid peripheral arterial disease patients and coronary artery disease patients younger than 65 years, incremental cost-effectiveness ratios were above €50,000 in carotid artery disease patients and coronary artery disease patients older than 75 years. Conclusion Lifelong preventive treatment of coronary artery disease and peripheral arterial disease patients at risk of cardiovascular events with dual pathway inhibition improves health outcomes and seems overall cost-effective relative to aspirin antiplatelet therapy and also to clopidogrel antiplatelet therapy for peripheral arterial disease, particularly in comorbid patients, but not in older patients and in carotid artery disease patients. These findings may warrant a targeted approach.

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