COMPASS Dual Pathway Inhibition — EECC MCQ

Correct answer: B — Low-dose rivaroxaban plus aspirin reduced vascular events

The COMPASS trial (2017) randomised 27,395 patients with stable ASCVD to: (1) rivaroxaban 2.5 mg bd + aspirin 100 mg; (2) rivaroxaban 5 mg bd alone; (3) aspirin 100 mg alone. Results: rivaroxaban 2.5 mg + aspirin reduced the composite of CV death, stroke, or MI by 24% vs aspirin alone (HR 0.76). Major bleeding increased (3.1% vs 1.9%) but net clinical benefit (including fatal bleeding, intracranial haemorrhage) favoured the combination. The trial was terminated early for efficacy. The 2024 ESC CCS Guidelines recommend considering low-dose rivaroxaban + aspirin (Class IIa) for patients with stable CAD or PAD at high ischaemic risk without high bleeding risk. This addresses thrombotic residual risk — the concept that persistent thrombin generation drives events beyond what antiplatelet therapy alone can prevent.

Reference: ESC (2024): CCS Guidelines; COMPASS Trial: https://bnf.nice.org.uk/