ATLAS - Rivaroxaban in patients with a recent ACS
ATLAS ACS 2-TIMI 51: Mega JL, et al. Rivaroxaban in patients with a recent acute coronary syndrome. NEJM 2012;366:9-19.
Bottom line:
Over ~13 months of follow-up, the addition of rivaroxaban 2.5 mg BID to ASA+clopidogrel/ticlopidine reduced the risk of CV events, mainly driven by fatal events, which led to lower all-cause mortality (NNT 63) in patients post-ACS. Adding rivaroxaban also reduced stent thrombosis (NNT 143). This came at the cost of a greater risk of major bleeds (NNH 84), including intracranial hemorrhages (NNH 500).
Adding rivaroxaban 5 mg BID did not reduce mortality, & further increased the risk of major bleeds.
It remains unclear which of the following regimens would have the best balance between efficacy & safety: Ticagrelor-based DAPT, clopidogrel-based DAPT + low-dose rivaroxaban, or ticagrelor-based DAPT + low-dose rivaroxaban.
Patients (n=15,526)
- Included
- ACS (within 7 days of admission, after revascularization if planned)
- Plus either
- Age >55 y
- Previous MI
- Diabetes
- Excluded
- Previous intracranial hemorrhage
- Clinically-significant GI bleed within 12 months
- CrCl <30 mL/min
- Hb <100 g/L
- Platelet count <90
- Baseline characteristics
- Age 61.5 y (9.6% 75 y or greater)
- Female 25%
- STEMI (~50%), NSTEMI (~25%), UA (~25%)
- Previous MI 27%
- CV risk factors: HTN ~67%, diabetes ~32%, dyslipidemia ~50%
- CrCl 86 mL/min
- Meds
- ASA 99%, P2Y12 inhibitor ~93%
- ACEI/ARB ~40%
- Beta-blocker ~66%
- Statin ~15%
Interventions
- Intervention1: Rivaroxaban 2.5 mg BID
- Intervention2: Rivaroxaban 5 mg BID
- Control: Placebo
- All groups: ASA + clopidogrel or ticlopidine
Results @ 13.1 months
Considerations
- Low risk of bias (allocation, performance, detection & attrition)
- Allocation concealed by central computer/phone allocation
- Participants, clinicians & investigators blinded to study drug
- Modified ITT & full ITT analysis
- 0.3% lost to follow-up, though ~28% in all groups discontinued study drug before end of study
- Generalizability
- Patients represented a group of post-ACS patients at very high risk of recurrent ASCVD with very low use of proven secondary prevention therapies
- Additionally, this trial was performed before approval of more potent P2Y12 inhibitors (prasugrel & ticagrelor), so background DAPT included ASA + clopidogrel/ticlopidine (how many specifically received clopidogrel not reported)
- Based on the preliminary results from ATLAS ACS-TIMI 46 (see below), the investigators selected 2.5 and 5 mg BID doses of rivaroxaban for this trial; this is pharmacokinetically rational given the 5-13h half-life of rivaroxaban (apixaban & dabigatran have similar half-lives and are generally dosed BID), however, it is a very different regimen than that used for AF/VTE. As a result, it's unclear if this regimen preserves the efficacy of rivaroxaban for these other conditions.
Summary of ATLAS ACS-TIMI 46
- Dose-ranging study with identical enrolment criteria as ATLAS ACS 2-TIMI 51