Original title: Reduction of Stent Thrombosis in Patients With Acute Coronary Syndromes Treated With Rivaroxaban in ATLAS-ACS 2 TIMI 51. Reference: C. Michael Gibson et al. J Am Coll Cardiol 2013;62:286–90.

There are few contemporary studies that investigated oral anticoagulation utility in patients with acute coronary syndromes and coronary angioplasty. Rivaroxaban is an oral anticoagulant that directly and selectively interrupts Xa factor preventing coagulation cascade and thus reducing the formation of thrombin.

Given its mechanism of action, this drug could be useful in reducing in-stent thrombosis, so this study tested prospectively the hypothesis in patients with acute coronary syndromes included in the study ATLAS-ACS 2 TIMI 51 (Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Standard Therapy in Subjects With Acute Coronary Syndrome Thrombolysis in Myocardial Infarction 51). The analysis was restricted to 9631 patients (63% of total) with a history of previous angioplasty or receiving angioplasty during the index hospitalization and were randomized to receive placebo 2 times per day, Rivaroxaban 2.5 mg or Rivaroxaban 5 mg. 

Rivaroxaban significantly reduced the definite and probable in- stent thrombosis (as defined by the Academic Research Consortium) considering both groups 2.5 and 5 mg (RR 0.65; P = 0.017) and the 2.5 mg group separately (RR 0.61, p = 0.023).  Reduced thrombosis was homogenous among patients receiving conventional stents and drug-eluting stents. Rivaroxaban benefit was observed during the period when patients were found with double anti aggregation (aspirin plus thienopyridine). 

Conclusion:

The factor Xa inhibitor Rivaroxaban significantly reduced in-stent thrombosis in patients suffering acute coronary syndrome. The benefit was seen especially during dual anti aggregation.

Editorial comment:

None of the patients with dual anti aggregation in this study received Prasugrel or Ticagrelor. This detail should not be overlooked against the common mistake of simply indicate all drugs that proved more effective, as even with the Clopidogrel, Rivaroxaban significantly increased bleeding and logically, we can expect more bleeding with a more powerful anti aggregation. 

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