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Stroke: Highlights of Selected Articles.

In the COMPASS MIND (MRI and Neurocognitive Deterioration Substudy of COMPASS), investigators aimed to evaluate the effect of rivaroxaban with and without aspirin on incident covert vascular brain disease and cognitive outcomes. Covert infarcts are common and associated with cognitive decline; however, whether the same therapies that prevent symptomatic stroke are also effective in preventing covert infarcts is unknown. In the original COMPASS study (Cardiovascular Outcomes for People Using Anticoagulation Strategies), the combination of rivaroxaban and aspirin significantly reduced the rate of ischemic stroke compared with aspirin or rivaroxaban alone in patients with stable cardiovascular disease. In the present study of 1445 participants, treatment with rivaroxaban plus aspirin did not significantly reduce covert infarcts compared with aspirin alone in the median follow-up of 2 years (2.7% versus 3.5%; OR, 0.77 [95% CI, 0.37–1.60]). There was no significant difference in the composite outcome of covert infarct or stroke between rivaroxaban plus aspirin versus aspirin alone (3.1% versus 5.3%; OR, 0.57 [95% CI, 0.30–1.09]) or in the rate of cerebral microbleeds across the two groups (7.1% rivaroxaban plus aspirin versus 5.1% aspirin alone). Similarly, there was no significant treatment effect on cognitive outcomes. The incidence of covert infarcts was lower than expected (3.2%) and potentially due to the early termination of the COMPASS study. However, covert infarcts occurred 4.5× more than symptomatic infarcts, consistent with prior studies, and differed from symptomatic infarcts in size and location. This study suggests that the underlying causes of symptomatic versus covert infarcts may differ, and thus the response to antithrombotic therapy and other preventive measures warrants further investigation. See p 2901.