Physicians' Academy for Cardiovascular Education

Combination of NOAC plus aspirin in older PAD patients after limb revascularization

Low-dose rivaroxaban plus aspirin in older patients with peripheral artery disease undergoing acute limb revascularization: insights from the VOYAGER PAD trial

Literature - Krantz MJ, Debus SE, Hsia J et al., - Eur Heart J. 2021, doi:10.1093/eurheartj/ehab408

Introduction and methods

Age is an important risk factor for peripheral artery disease (PAD). Because of concern of higher bleeding risk with advanced age, patients with PAD are often undertreated compared with coronary artery disease (CAD) counterparts [1]. Bleedings scores as ACUITY, CRUSADE, DAPT and PRECISE-DAPT reinforce the clinical uncertainty with regard to benefit-risk ratio for initiation of antithrombotic therapy in older patients with atherosclerosis [2,3].

This study examined the benefit-risk balance of use of combination antithrombotic therapy in PAD patients ≥75 years, acutely after percutaneous or surgical lower extremity revascularization (LER) using data of the VOYAGER PAD trial [4].

VOYAGER PAD was a randomized, double-blind, placebo-controlled trial. Results showed that in PAD patients who had undergone LER, treatment with rivaroxaban (2.5 mg twice daily) with aspirin as compared to aspirin alone significantly reduced risk of ischemic limb and CV events. Older age in the study was pre-specified as ≥75 years. Primary efficacy outcome was composite of ALI, major amputation of a vascular etiology, MI, ischemic stroke or CV death. The principal safety outcome was TIMI major bleeding.

Main results


This analysis of VOYAGER PAD showed that low-dose rivaroxaban in addition to aspirin reduced risk of ischemic events (including severe limb complications) with consistent benefit across the spectrum of age (comparing patients ≥75 years vs. < 75 years). TIMI major bleeding was increased by rivaroxaban, but not ICH or fatal bleeding. Overall, benefit-risk profile appears favorable in PAD patients, also in those ≥75 years.


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Find this article online at Eur Heart J.

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