Dual pathway inhibition as compared to acetylsalicylic acid monotherapy in relation to endothelial function in peripheral artery disease, a phase IV clinical trial

Loes H Willems; Dick H J Thijssen; Laszlo A Groh; Nina I Kooijman; Hugo Ten Cate; Henri M H Spronk; A Rogier T Donders; Rozemarijn J van der Vijver-Coppen; Frank van Hoek; Magdolna Nagy; Michel M P J Reijnen; Michiel C Warlé

doi:10.3389/fcvm.2022.979819

Dual pathway inhibition as compared to acetylsalicylic acid monotherapy in relation to endothelial function in peripheral artery disease, a phase IV clinical trial

Front Cardiovasc Med. 2022 Oct 6:9:979819. doi: 10.3389/fcvm.2022.979819. eCollection 2022.

Authors

Affiliations

¹ Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands.
² Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
³ Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom.
⁴ Departments of Internal Medicine and Biochemistry, Maastricht University Medical Center (MUMC) and Cardiovascular Research Institute Maastricht (CARIM) School for Cardiovascular Diseases, Maastricht, Netherlands.
⁵ Center for Thrombosis and Haemostasis, Gutenberg University Medical Center, Mainz, Germany.
⁶ Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
⁷ Department of Surgery, Rijnstate Hospital, Arnhem, Netherlands.
⁸ Multi-Modality Medical Imaging Group, Faculty of Science and Technology, University of Twente, Enschede, Netherlands.

Abstract

Objective: Dual pathway inhibition (DPI) by combining acetylsalicylic acid (ASA) with low-dose rivaroxaban has been shown to reduce cardiovascular events in patients with peripheral arterial disease (PAD) when compared to ASA monotherapy. A potential explanation is that inhibition of factor Xa improves endothelial function through crosstalk between coagulation and inflammatory pathways, subsequently attenuating the occurrence of cardiovascular events. We hypothesize that the addition of rivaroxaban to ASA in PAD patients leads to improved endothelial function.

Design: An investigator-initiated, multicentre trial investigating the effect of DPI on endothelial function.

Methods: Patients, diagnosed with PAD, were enrolled in two cohorts: cohort A (Rutherford I-III) and cohort B (Rutherford IV-VI). Participants received ASA monotherapy for a 4-weeks run-in period, followed by 12 weeks of DPI. Macro- and microvascular endothelial dysfunction were studied by measuring carotid artery reactivity upon sympathetic stimulus and by measuring plasma endothelin-1 concentrations, respectively. All measurements were performed during the use of ASA (baseline) and after 12 weeks of DPI.

Results: 159 PAD patients (111 cohort A, 48 cohort B) were enrolled. Twenty patients discontinued study drugs early. Carotid artery constriction upon sympathetic stimulation at baseline (ASA) and after 12 weeks of DPI was similar in the total group, 22.0 vs. 22.7% (p = 1.000), and in the subgroups (Cohort A 22.6 vs. 23.7%, p = 1.000; cohort B 20.5 vs. 20.5%, p = 1.000), respectively. The mean concentration of plasma endothelin-1 at baseline and after 12 weeks of DPI did not differ, 1.70 ± 0.5 vs. 1.66 ± 0.64 pmol/L (p = 0.440) in the total group, 1.69 ± 0.59 vs. 1.62 ± 0.55 pmol/L in cohort A (p = 0.202), and 1.73 ± 0.53 vs. 1.77 ± 0.82 pmol/L in cohort B (p = 0.682), respectively.

Conclusion: Macro- and microvascular endothelial dysfunction, as reflected by carotid artery reactivity and plasma endothelin-1 concentrations, are not influenced in PAD patients by addition of low-dose rivaroxaban to ASA monotherapy for 12 weeks.

Trial registration: https://clinicaltrials.gov/ct2/show/NCT04218656.

Keywords: aspirin; endothelial cells; factor Xa inhibitors; peripheral arterial disease; rivaroxaban; vascular endothelium.

Associated data

ClinicalTrials.gov/NCT04218656