A 68-year-old female patient with a medical history of obstructive sleep apnea, hypertension, prior transient ischemic attack, hyperlipidemia, Class III obesity, and prior percutaneous coronary intervention of the left circumflex artery in 2018 presents to her cardiologist for routine follow-up. Her medications include aspirin 81 mg daily, carvedilol 12.5 mg twice daily, lisinopril 5 mg daily, and atorvastatin 40 mg daily. She uses continuous positive airway pressure nightly.
In 2018, she had developed chest pain with walking. On the day of presentation, she had chest pain that occurred at rest that prompted her to present to the emergency department. A physical examination was normal, but electrocardiogram demonstrated T-wave inversions in the lateral precordial leads. A high-sensitivity troponin was elevated to 984 ng/L. She was referred for coronary angiogram, which showed single-vessel disease with significant stenosis of the proximal left circumflex artery. She underwent successful percutaneous intervention with placement of a drug-eluting stent at that time. She was started on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. Clopidogrel was discontinued after 12 months. A review of symptoms at time of discontinuation was negative for chest pain, bruising, bleeding, melena, or hematochezia.
Today in clinic, she reports no chest pain with walking to work. On examination, her heart rate is 61 bpm, and her blood pressure is 129/74 mmHg. Her weight is 126.1 kg (278 lbs), and she is 180.3 cm (70.9 in) tall, resulting in a body mass index of 38.8 kg/m2. Laboratory results reveal total cholesterol of 129 mg/dL, high-density lipoprotein cholesterol of 44 gm/dL, low-density lipoprotein cholesterol of 69 mg/dL, and triglycerides of 268 mg/dL.
The correct answer is: D. Start low-dose rivaroxaban
This patient has stable ischemic heart disease (SIHD). The addition of low-dose rivaroxaban to aspirin has been shown to decrease the risk of myocardial infarction, stroke, and cardiovascular death without an increase in fatal bleeding.1 Given the potential for altered pharmacokinetics and pharmacodynamics of direct oral anticoagulants in patients with obesity, concerns have been raised about safety and efficacy of the use of direct oral anticoagulants across weight categories. However, a recent subgroup analysis from the COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial demonstrated similar safety and efficacy in patients with obesity up to a body mass index of 39.9 kg/m2.2 In addition to starting low-dose rivaroxaban, the patient should be encouraged to reduce her weight through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs.3
Treatment with prasugrel in addition to aspirin is not indicated in patients with a prior history of transient ischemic attack given the increased risk for significant bleeding (Class of Recommendation: III: Harm; Level of Evidence: B-R).4 Among patients with SIHD who are treated with DAPT after placement of a drug-eluting stent for acute coronary syndrome, it is reasonable to continue DAPT for longer than 12 months if they have tolerated the therapy without bleeding complication and are at low risk (Class of Recommendation: IIb; Level of Evidence: A).4 The patient's blood pressure is already adequately controlled on her current regimen of lisinopril and carvedilol. Additionally, her SIHD is asymptomatic and does not require the addition of another anti-anginal agent at this time. The patient's low-density lipoprotein cholesterol is also at the goal of <70 mg/dL for patients with established coronary artery disease.5
References
- Eikelboom JW, Connolly SJ, Bosch J, et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med 2017;377:1319-30.
- Guzik TJ, Ramasundarahettige C, Pogosova N, et al. Rivaroxaban Plus Aspirin in Obese and Overweight Patients With Vascular Disease in the COMPASS Trial. J Am Coll Cardiol 2021;77:511-25.
- Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-e164.
- Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016;68:1082-115.
- Grundy SM, Cleeman JI, Bairey Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227-39.
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