Abstract
Chronic coronary artery disease (CAD) remains a leading cause of morbidity and mortality
worldwide, despite advances in pharmacological and interventional therapies. Aspirin
has long been the cornerstone of secondary prevention; however, residual cardiovascular
risk persists in many patients, especially those with additional high-risk features
such as diabetes, polyvascular disease, or renal dysfunction. The concept of dual
pathway inhibition (DPI) combining low-dose anticoagulation with antiplatelet therapy
has emerged as a novel strategy to enhance vascular protection. The COMPASS trial
provided pivotal evidence supporting the use of low-dose rivaroxaban (2.5 mg twice
daily) in combination with aspirin (100 mg daily), demonstrating significant reductions
in major adverse cardiovascular events without a corresponding increase in fatal or
intracranial bleeding. While the COMPASS study enrolled patients with sinus rhythm
(oral anticoagulation naive) and used a special dose of DAOC, the recently published
AQAUTIC study looked at CAD with prior oral anticoagulation. There was no benefit
of adding aspirin to standard dose anticoagulation, and hence, such patients are not
candidates for DPI. This review explores the rationale behind DPI, key findings from
the COMPASS trial in chronic CAD patients, and the implications for clinical practice.
It also discusses patient selection strategies, drug interactions, safety considerations,
and current guideline recommendations. A proposed clinical algorithm is presented
to guide the practical application of DPI in appropriately selected patients with
stable CAD, aiming to redefine secondary prevention and improve long-term cardiovascular
outcomes.
Keywords
chronic coronary artery disease - rivaroxaban - aspirin - antithrombotic therapy -
high-risk CAD - cardiovascular outcomes
