Patients with vascular diseases such as coronary artery disease (CAD) and peripheral artery disease (PAD) remain at a significant risk of catastrophic health events despite receiving the current standard of care. A recent groundbreaking study identifying those at greatest risk was published on January 11, 2024, in the prestigious American Heart Journal (DOI: 10.1016/j.ahj.2024.01.001).

The XATOA Registry, spearheaded by renowned experts such as Dr. Sonia S. Anand from the Population Health Research Institute in Hamilton, Canada, among others, has provided imperative insights on patient groups with CAD and/or PAD who may benefit from intensified medical intervention, with results suggesting impactful implications for clinical practices worldwide.

The XATOA Registry: Casting a Wide Net

Running from November 2018 to May 2020, the XATOA Registry was a single-arm study embracing a broad spectrum of vascular patients. This mammoth undertaking amassed a cohort of 5,808 participants, with 5,532 individuals satisfying the criteria for comprehensive analysis. The median follow-up period stretched 462 days, offering substantial data to distill vital findings.

Participants of XATOA were administered a combination of low-dose rivaroxaban (2.5 mg, BID) along with aspirin, which assisted researchers in documenting the occurrence of major adverse cardiovascular events (MACE), major adverse limb events (MALE), and major bleeding incidents.

 Identifying the Crux of the Problem: Polyvascular Disease

A paramount discovery emerged when the data revealed that individuals grappling with polyvascular disease – a condition where two or more vascular beds are compromised – constituted the group at the highest risk.
The statistics are stark: the incidence risk of MACE or MALE in these polyvascular patients was a staggering 9.16 per 100 patient-years compared to just 2.48 for those with single vascular bed involvement.

Age, Diabetes, Heart Failure, and Chronic Renal Insufficiency: Additional Risk Factors

Alarmingly, the study also pinpointed additional subgroups of high-risk patients that include those aged 75 years or older, and those with a history of diabetes, heart failure, or chronic renal insufficiency (CRI).

Analyzing the Risks: Classification and Regression Tree Analysis

Employing classification and regression tree analysis (CART), the study’s authors could distill the data further. They identified polyvascular disease as the predominant risk factor that segregated higher-risk patients from their lower-risk counterparts.

This risk exacerbated when patients also suffered from comorbid conditions such as chronic renal insufficiency (CRI) or diabetes, showcasing the need for more focused care strategies in such populations.

A Silver Lining: Low Rates of Major Bleeding

Though the study highlighted the high risks of MACE and MALE in certain populations, it also delivered some positive findings in terms of the safety profile of the combination therapy involving low-dose rivaroxaban and aspirin. The rates of major bleeding were reported to be low among the participants, hinting at the tolerability of the regimen.

Implications for Clinical Practice

This colossal repository of data from the XATOA Registry propounds an urgent call for prioritizing patients with polyvascular disease to receive maximal medical therapy with low dose rivaroxaban and aspirin, propelling a potential paradigm shift in treatment stratification.

Dr. Sonia S. Anand, the lead author of the study, argues for an aggressive and informed approach to managing patients with polyvascular disease, given their pronounced risk profile. She states, “Our study underscores an inevitable reality—the need for vigilant, comprehensive care for those with complex vascular conditions. The medical community should hearken to these findings and optimize treatment protocols for those in dire need.”


The data emerging from the XATOA Registry holds a mirror to the cardiovascular community, reflecting upon the high stakes involved in managing patients with polyvascular disease and other associated risk factors. By identifying the highest-risk individuals, this study pioneers a significant forward leap in vascular health management.

The study may serve as a beacon for future research and as a guide for healthcare providers to tailor treatments that could strategically reduce the incidence of severe vascular events in patients most vulnerable to them.


Anand, S. S., Aboyans, V., Bosch, J., Debus, S., Gay, A., Patel, M. R., Vogtländer, K., Welsh, R. C., Zeymer, U., Fox, K. A. A., & XATOA Steering Committee. (2024). Identifying the Highest Risk Vascular Patients: insights from the XATOA Registry. American Heart Journal. DOI: 10.1016/j.ahj.2024.01.001.

The article also mentions multiple declarations of competing interests among the authors, with various forms of honoraria being received from pharmaceutical entities such as Bayer AG.


1. Vascular Patient Risk
2. XATOA Registry Study
3. Polyvascular Disease Treatment
4. Low-Dose Rivaroxaban
5. Major Adverse Cardiovascular Events

The article, with its detailed insights, is tailored to clinicians, patients, and the broader healthcare community, seeking to inform and steer toward enhanced clinical practices for those with significant vascular health challenges.