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Dual Pathway Inhibition — RACP Adult Medicine MCQ

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ModerateCardiologyDual Pathway InhibitionRACP Adult Medicine

A 55-year-old man with known stable coronary artery disease is on aspirin 100 mg, atorvastatin 40 mg, perindopril 10 mg, and metoprolol 50 mg BD. He develops claudication symptoms. His ankle-brachial index is 0.6. What modification to his antiplatelet/antithrombotic therapy should be considered?

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Reveal the answer and explanation

Correct answer: B — No change

The COMPASS trial demonstrated that rivaroxaban 2.5 mg BD plus aspirin 100 mg daily (dual pathway inhibition) significantly reduces major adverse cardiovascular events and limb events compared to aspirin alone in patients with stable CAD and/or PAD. It is particularly beneficial for patients with polyvascular disease (CAD + PAD as in this case). The NNT is favourable but there is an increase in major bleeding (though not fatal or intracranial). This combination is PBS-listed in Australia for patients with CAD and PAD.

Reference: NHF/CSANZ – 2025 – ACS Guideline; COMPASS Trial – 2017