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New Clinical Guidelines for Patients at High Risk of Cardiovascular Disease

Clinical practice guidelines recommended by the European Society of Cardiology (ESC) include dosage of drugs and changes in nomenclature.

The European Society of Cardiology (ESC) has published new clinical practice guidelines on the management of diabetes and ‘chronic coronary syndromes (CCS)’, which replace the 2013 recommendations for the management of stable coronary artery disease (CAD). The guidelines now recommend that treatment with rivaroxaban vascular dose (2.5 mg twice daily) plus aspirin low dose once daily should be considered in the treatment of patients with chronic coronary syndromes at high risk of further events and low risk of bleeding. Another new ESC guideline addressing diabetes also includes such a recommendation for this regimen in patients with diabetes and lower extremity arterial disease. A new analysis of the COMPASS study published in the Journal of the American College of Cardiology in July this year has demonstrated that patients with high risk factors benefited most from dual pathway inhibition with rivaroxaban and aspirin.

The new guidelines also include a change in nomenclature from stable coronary artery disease to CCS. The change reflects the reality that these patients with CCS are at continuous risk for heart attacks and strokes. The underlying disease status of coronary artery disease, atherosclerotic plaque accumulation, is a dynamic process that can lead to life threatening thrombotic events including strokes and heart attacks, which remain the main cause of death worldwide.

This recommendation is based on data from the Phase III COMPASS study, which showed that rivaroxaban vascular dose plus aspirin 100 mg once daily reduced the composite risk of stroke, cardiovascular death and heart attack by 24 percent (relative risk reduction) compared with aspirin 100 mg once daily alone in patients with CAD or PAD, including a 42 percent relative risk reduction in stroke and an 18 percent mortality reduction. The Phase III randomized controlled COMPASS study was published in 2017, after it was stopped one year ahead of schedule due to overwhelming efficacy.

A new analysis of the COMPASS study published in the Journal of the American College of Cardiology in July this year demonstrated that the protection provided by rivaroxaban vascular dose plus aspirin 100 mg once daily is especially pronounced in patients with at least one of the following risk factors: involvement of two or more vascular beds, diabetes, renal impairment or a history of heart failure. These patients had a 2-fold increase in vascular events when compared to those individuals without these risk factors.

The guidelines also emphasize the crucial role of healthy lifestyle behaviours, medication and other preventive actions in decreasing the risk of subsequent cardiovascular events and mortality.

“The burden of stroke and heart attack has been rising in Asia Pacific and causing a huge strain on health systems. The new ESC clinical practice guidelines, reflecting the latest research, will support doctors in the timely adoption of a new treatment approach which addresses the unmet needs for more effective prevention of these serious cardiovascular events in CAD patients who are at risk,” said Dr. Jack Tan, President of the Asian Pacific Society of Cardiology (APSC). [APBN]