Life and limb protection with dual anti-thrombotic pathway inhibition: COMPASS ushers in a new day in atherothrombotic risk reduction

Inhibiting thrombosis is a cornerstone of vascular protection. Antiplatelet therapies, like aspirin and P2Y₁₂ inhibitors, are used to prevent thrombosis and are widely endorsed in current clinical practice recommendations. Recent data suggest that "dual anti-thrombotic pathway inhibition" targeting platelets and coagulation may further reduce the residual atherosclerotic risk. This innovative thesis was tested in the COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial, which demonstrated that a combination of aspirin and low-dose rivaroxaban (2.5 mg twice daily) reduced cardiovascular events (including mortality) in patients with stable coronary or peripheral artery disease. Here we offer a bench-to-bedside synopsis of this important translational advance for clinicians and scientists. We focus specifically on patient subgroups that appear to derive the greatest absolute risk reduction, including those with polyvascular disease, type 2 diabetes, heart failure, and renal disease. In addition, we provide a practical algorithm to help clinicians determine whether to switch their patients to dual anti-thrombotic pathway inhibition.