Net clinical benefit of extended dual pathway inhibition according to baseline risk in patients with chronic coronary syndrome: a COMPASS substudy

TY - JOUR

T1 - Net clinical benefit of extended dual pathway inhibition according to baseline risk in patients with chronic coronary syndrome

T2 - a COMPASS substudy

AU - Würtz, Morten

AU - Olesen, Kevin Kris Warnakula

AU - Bhatt, Deepak L

AU - Yusuf, Salim

AU - Muehlhofer, Eva

AU - Eikelboom, John W

AU - Maeng, Michael

N1 - Publisher Copyright: © 2024 Oxford University Press. All rights reserved.

PY - 2024/4/1

Y1 - 2024/4/1

N2 - Aims Guidelines recommend extended dual pathway inhibition (DPI) with aspirin and rivaroxaban in patients with chronic coronary syndrome (CCS) at high ischaemic risk. The CHADS-P2A2RC score improves risk prediction and enables antithrombotic treatment allocation in these patients. This study evaluated the net clinical benefit of DPI treatment according to baseline risk as classified by the CHADS-P2A2RC score in patients with CCS included in the COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial. Methods and COMPASS patients with CCS (n = 14 670), randomized to aspirin alone or DPI, were stratified according to cardiovascuresults lar risk using the CHADS-P2A2RC score. Endpoints were major adverse cardiovascular events (MACE), all-cause death, fatal/critical organ bleeding, and composite adverse events (MACE and bleeding). Net clinical benefit was the 30-month risk difference of MACE and bleeding. Thirty-month incidences of MACE [7.9% vs. 3.9%, hazard ratio (HR) 2.01, 95% confidence interval (CI) 1.83–2.18] and fatal/critical organ bleeding (1.2% vs. 0.8%, HR 1.49, 95% CI 1.06–1.92) were higher in high-risk (CHADS-P2A2RC ≥ 4) than in low/moderate-risk (CHADS-P2A2RC < 4) patients. DPI reduced MACE (low/moderate risk: HR 0.62, 95% CI 0.47–0.82; high risk: HR 0.82, 95% CI 0.68–0.99, P for interaction 0.09) and all-cause death (low/moderate risk: HR 0.65, 95% CI 0.46–0.91; high risk: HR 0.81, 95% CI 0.65–1.00, P for interaction 0.29), without substantially increasing fatal/critical organ bleeding (low/moderate risk: HR 1.35, 95% CI 0.72–2.53; high risk: HR 1.18, 95% CI 0.73–1.90, P for interaction 0.73). DPI provided net clinical benefit of similar magnitude in low/moderate-risk (−1.81%, 95% CI −3.00 to −0.62) and high-risk (−1.96%, 95% CI −3.60 to −0.33) CCS patients. Conclusion As classified by the CHADS-P2A2RC score, low/moderate- and high-risk patients with CCS derived similar net clinical benefit and reduction in all-cause death from DPI treatment.

AB - Aims Guidelines recommend extended dual pathway inhibition (DPI) with aspirin and rivaroxaban in patients with chronic coronary syndrome (CCS) at high ischaemic risk. The CHADS-P2A2RC score improves risk prediction and enables antithrombotic treatment allocation in these patients. This study evaluated the net clinical benefit of DPI treatment according to baseline risk as classified by the CHADS-P2A2RC score in patients with CCS included in the COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial. Methods and COMPASS patients with CCS (n = 14 670), randomized to aspirin alone or DPI, were stratified according to cardiovascuresults lar risk using the CHADS-P2A2RC score. Endpoints were major adverse cardiovascular events (MACE), all-cause death, fatal/critical organ bleeding, and composite adverse events (MACE and bleeding). Net clinical benefit was the 30-month risk difference of MACE and bleeding. Thirty-month incidences of MACE [7.9% vs. 3.9%, hazard ratio (HR) 2.01, 95% confidence interval (CI) 1.83–2.18] and fatal/critical organ bleeding (1.2% vs. 0.8%, HR 1.49, 95% CI 1.06–1.92) were higher in high-risk (CHADS-P2A2RC ≥ 4) than in low/moderate-risk (CHADS-P2A2RC < 4) patients. DPI reduced MACE (low/moderate risk: HR 0.62, 95% CI 0.47–0.82; high risk: HR 0.82, 95% CI 0.68–0.99, P for interaction 0.09) and all-cause death (low/moderate risk: HR 0.65, 95% CI 0.46–0.91; high risk: HR 0.81, 95% CI 0.65–1.00, P for interaction 0.29), without substantially increasing fatal/critical organ bleeding (low/moderate risk: HR 1.35, 95% CI 0.72–2.53; high risk: HR 1.18, 95% CI 0.73–1.90, P for interaction 0.73). DPI provided net clinical benefit of similar magnitude in low/moderate-risk (−1.81%, 95% CI −3.00 to −0.62) and high-risk (−1.96%, 95% CI −3.60 to −0.33) CCS patients. Conclusion As classified by the CHADS-P2A2RC score, low/moderate- and high-risk patients with CCS derived similar net clinical benefit and reduction in all-cause death from DPI treatment.

KW - Aspirin

KW - Chronic coronary syndrome

KW - Coronary artery disease

KW - Myocardial infarction

KW - Platelet inhibitors

KW - Rivaroxaban

KW - Risk Assessment

KW - Humans

KW - Middle Aged

KW - Male

KW - Treatment Outcome

KW - Purinergic P2Y Receptor Antagonists/adverse effects

KW - Hemorrhage/chemically induced

KW - Aspirin/adverse effects

KW - Factor Xa Inhibitors/adverse effects

KW - Rivaroxaban/adverse effects

KW - Time Factors

KW - Platelet Aggregation Inhibitors/adverse effects

KW - Female

KW - Aged

KW - Heart Disease Risk Factors

KW - Dual Anti-Platelet Therapy/adverse effects

KW - Chronic Disease

UR - http://www.scopus.com/inward/record.url?scp=85194162936&partnerID=8YFLogxK

U2 - 10.1093/ehjcvp/pvae017

DO - 10.1093/ehjcvp/pvae017

M3 - Journal article

C2 - 38453426

SN - 2055-6837

VL - 10

SP - 201

EP - 209

JO - European heart journal - Cardiovascular pharmacotherapy

JF - European heart journal - Cardiovascular pharmacotherapy

IS - 3

ER -