Reduction of Stent Thrombosis in Patients with Acute Coronary Syndrome Treated with Rivaroxaban in ATLAS ACS 2-TIMI 51
Selected in Journal of the American College of Cardiology by M Bollati
Michael Gibson C, Chakrabarti AK, Mega J, Bode C, Bassand JP, Verheugt FW, Bhatt DL, Goto S, Cohen M, Mohanavelu S, Burton P, Stone G, Braunwald E
J Am Coll Cardiol. 2013 Apr 16. pii: S0735-1097(13)01486-1
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What is known
Stents and drug eluting stents (DES) reduced significantly in stent restenose. In other hand, especially DES are related to higher stent thrombosis, a well known high risk complication. Ancillary drug therapy, as the dual antiplatelet therapy (DAPT), reduce significantly the rate of this complication, but about 1% of patients are still at risk.
This study evaluates the results of adjunctive anticoagulant therapy with Rivaroxaban to normal DAPT in patient with stenting after acute coronary syndrome selected in the ATLAS ACS 2 TIMI 51 trial. Three groups are identified: 1) rivaroxaban 5 mg twice daily, 2) rivaroxaban 2,5 mg twice daily, 3) placebo
The findings are:
- After 2 years, stent thrombosis (definite or possible by ARC) was 1,9% for the placebo group and 1,5% for the Rivaroxaban group (p=0,008)
- Cardiovascular mortality was 2,3% vs 1,4% (p=0,014), in favour of 2,5 mg twice daily Rivaroxaban group
One drug more. But is it really useful? It may be, but there are several lack of evidence.
The trial is well designed and conducted (more than 9.000 patients) and the data regarding cardiovascular mortality seem to be encouraging, but no clear information about hemorragic events and overall mortality are still provided by the Authors (we have the data only from the general trial considering the patients without stenting too). Moreover, the major stent thrombosis reduction is related to Rivaroxaban 2,5 mg than 5mg, and this relation is still without a clear explanation.
At the moment, these results in the overall post-stenting population have to be considered as borderline and they need further investigations.
Interesting data may be found after a special patients selection: why not evaluate rivaroxaban in patient with high platelet reactivity or previous stent thrombosis?