Abstract 16428: Impact of Low-Dose Rivaroxaban Plus Aspirin on Myocardial Infarction in Patients With Peripheral Artery Disease With and Without Concomitant Coronary Artery Disease: Insights From VOYAGER PAD
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abstract
Background:
Patients with peripheral artery disease (PAD) are at heightened risk of major adverse cardiovascular events (MACE). In VOYAGER PAD, rivaroxaban 2.5 mg BID reduced ischemic risk in PAD patients after lower extremity revascularization (LER). Whether the benefits for MACE and in particular for Myocardial Infarction (MI) differ in those with and without clinically known coronary artery disease (CAD) has not been described.
Hypothesis and Methods:
VOYAGER PAD randomized patients with symptomatic PAD undergoing LER to rivaroxaban 2.5 mg BID plus aspirin versus aspirin alone. MACE was defined as composite of MI, ischemic stroke, or cardiovascular death. Subtypes of MI were adjudicated according to the Universal Definition. Comorbid CAD was a prespecified subgroup.
Results:
Of 6,564 symptomatic PAD randomized, 2,083 (32%) had documented CAD at baseline. The benefit of rivaroxaban plus aspirin was greater for MACE in those with vs without CAD (HR 0.79, 95% CI 0.62 - 1.00 vs HR 1.12, 95% CI 0.92 - 1.36; p-interaction 0.03). Similarly, MI reduction with rivaroxaban plus aspirin was greater for those with vs without CAD (HR 0.78, 95% CI 0.56 - 1.10 vs HR 0.96, 95% CI 0.69 - 1.34; p-interaction 0.39). Considering MI subtypes, the effect of rivaroxaban plus aspirin on type 1 MI was consistent in patients with CAD (HR 0.91, 95% CI 0.58 - 1.42) and without CAD (HR 0.74, 95% CI 0.74 - 1.11, p-interaction 0.50). However, a trend towards benefit of rivaroxaban plus aspirin was seen for Type 2 MI in those with CAD (HR 0.71, 95% CI 0.41 - 1.24) but not in patients without CAD (HR 1.66, 95% CI 0.89 - 3.09, p-interaction 0.0475, figure). Type 4 MI was infrequent regardless of CAD.
Conclusions:
Rivaroxaban plus aspirin had consistent effects in MACE for PAD and CAD patients undergoing LER. Our analysis of MI subtype suggests that events adjudicated as MI due to supply demand mismatch (Type 2) may have a thrombotic component and are lowered with rivaroxaban and aspirin in PAD and CAD patients undergoing LER.
