Low-dose rivaroxaban was effective in secondary prevention of atherosclerotic cardiovascular
disease (ASCVD) in the COMPASS trial. There is no established role, however, for oral
anticoagulants in primary prevention. We evaluated whether coronary artery calcium
(CAC) scoring identifies a high-risk primary prevention adult population who may benefit
from low-dose rivaroxaban to prevent ASCVD events. We modeled expected outcomes of
low-dose rivaroxaban in 5,196 Multiethnic Study of Atherosclerosis (MESA) cohort participants
not already on antiplatelet or anticoagulant therapy. We applied relative risk ratios
from COMPASS to absolute MESA event rates in order to estimate number needed to treat
(NNT) to avoid a composite of cardiovascular death, nonfatal myocardial infarction,
or nonfatal stroke, as well as number needed to harm (NNH) to cause 1 hospitalized
bleed; with both NNT and NNH stratified by calculated ASCVD risk and by baseline CAC.
MESA participants with CAC ≥300 had crude ASCVD event rate of 20 per 1000 patient-years,
which is comparable to that observed in the COMPASS control-arm. CAC was independently
associated with the composite ASCVD outcome (p <0.001 for trend). However, CAC was
not independently associated with adjusted hazard ratio for hospitalized major bleeding.
Predicted 5-year NNT (modeled from COMPASS) was 75 in persons with CAC 100-299 and
45 with CAC ≥300 despite NNH values of 252 and 98, respectively. In conclusion, CAC
helps to distinguish estimated ASCVD benefit from estimated bleeding harm, thereby
identifying very high-risk primary prevention adults without established cardiovascular
disease who may derive net-benefit from low-dose rivaroxaban.
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Article info
Publication history
Published online: July 24, 2019
Received in revised form:
July 8,
2019
Received:
June 19,
2019
Footnotes
Funding: The MESA study is supported by contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168 and N01-HC-95169 from the National Heart, Lung, and Blood Institute, and by grants UL1-TR-000040, UL1-TR-001079, and UL1-TR-001420 from the National Center for Research Resources.
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