Following the COMPASS: Antithrombotic Prescription Trends in Patients With Symptomatic Peripheral Arterial Disease Following Revascularization

BACKGROUND:The VOYAGER PAD trial demonstrated the superiority of aspirin (ASA) and low dose rivaroxaban (COMPASS trial dosing) compared with ASA alone in reducing MACE (Major adverse cardiovascular events) and MALE (Major adverse limb events). We studied the COMPASS discharge prescription patterns in patients with symptomatic PAD who have undergone revascularization in our institution, since the time of publication of the VOYAGER PAD trial. METHODS:All patients included in this study had documented lower extremity atherosclerotic PAD and were eligible for COMPASS dosing. Revascularization strategies included endovascular (n=299), suprainguinal bypass (n=18), and infrainguinal bypass (n=36). RESULTS:COMPASS prescription patterns for the composite of endovascular and surgical strategies demonstrated a consistently low rate over time, without a trend towards increasing use. COMPASS dosing was prescribed as often as antiplatelet monotherapy (33.4% COMPASS vs. 34.6% antiplatelet monotherapy). This low COMPASS prescription rate was driven by significantly lower COMPASS prescriptions following endovascular therapy compared to surgical bypass (28.8% endovascular vs. 59.3% surgical bypass). COMPASS prescriptions following surgical bypass showed better trends; one-half of suprainguinal bypass patients (50.0%) and two-thirds of infrainguinal bypass patients (63.9%) were discharged on COMPASS. Despite patients with chronic limb threatening ischemia (CLTI) representing a high-risk limb presentation, COMPASS prescriptions were low (29.8%), as opposed to patients without CLTI, and did not show a trend towards increasing use. In patients who underwent re-interventions throughout the observation period, there was a low conversion rate from ASA alone to COMPASS (3/26, 11.5%). CONCLUSION:In this observational study, one-third of patients were under-treated by prescription of antiplatelet monotherapy, indicating that there is significant room for medical optimization. This is especially true of patients undergoing endovascular treatment, including the high-risk subgroup of patients with CLTI. We highlight the importance of dual pathway antithrombotic therapy in patients eligible for COMPASS dosing to optimize best current evidence medical therapy.