Low-Dose Rivaroxaban Plus Aspirin: A New Way to Prevent Strokes?
Philip Chang, MD
Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O, et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med. 2017
This landmark trial published in the New England Journal of Medicine found that in 27,395 patients with stable atherosclerotic cardiovascular disease (ASCVD), aspirin 100 daily plus rivaroxaban 2.5mg twice daily was superior to aspirin alone and rivaroxaban alone in preventing the primary outcome of cardiovascular death, stroke, or heart attack. In addition, secondary outcomes of all-cause death were also significantly lower in the aspirin-plus-rivaroxaban group. The effect size was large enough for the study to stop prematurely for superiority of the aspirin-plus-rivaroxaban group. From this, it is clear that treatment with rivaroxaban plus aspirin is superior to aspirin alone in a patient with coronary or peripheral vascular disease in preventing ischemic stroke (p=<0.001) without significantly increased adverse effects. However, this brings into the question – what about patients who already have a history of ischemic stroke? Ischemic stroke is an ASCVD risk equivalent, and this study brings into question – do we need to start adding apixaban for secondary ischemic stroke prevention for all-comers?