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Rymer J, Pichan C, Page C, Alhanti B, Bhatt DL, Kochar A, Angiolillo DJ, Diaz M, Wimmer NJ, Waksman R, Ang L, Bach R, Jenkins R, El-Sabae H, Brothers L, Ohman EM, Jones WS, Washam JB, Wang TY, Narcisse D, Basir MB. The Use of Cangrelor in Cardiogenic Shock: Insights from the CAMEO Registry. J Card Fail 2024; 30:1233-1240. [PMID: 39389732 DOI: 10.1016/j.cardfail.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 08/02/2024] [Accepted: 08/02/2024] [Indexed: 10/12/2024]
Abstract
INTRODUCTION Little is known about the use of cangrelor in patients with myocardial infarction (MI) presenting with cardiogenic shock (CS). METHODS CAMEO (Cangrelor in Acute MI: Effectiveness and Outcomes) is a multicenter observational registry evaluating platelet inhibition in patients with MI. We examined the duration of cangrelor infusion and the amount of time to transition from cangrelor to an oral P2Y12 inhibitor in patients with CS. We also assessed major adverse cardiovascular events (MACEs) and bleeding risks, stratified by dosage duration, time to transition and oral P2Y12 inhibitor potency. RESULTS Among 2352 cangrelor-treated patients with MI, 249 patients were in CS. Among the patients with CS, 16 (6.4%) received the "bridge" infusion dose, 202 (81.1%) the PCI cangrelor infusion dose, and 30 (12.0%) had a combination of both infusion doses. Patients with CS had a median age of 66 years; 32% were women; 21% were Black patients; 35% had diabetes; 19% received thrombectomy; and 59% received mechanical circulatory support (MCS) (35% intra-aortic balloon pump, 27% Impella). The median duration of infusion was 3.9 (2-21.5 hours) in patients with CS and was 2 (1.6-3.1 hours) for all cangrelor-treated patients. The median duration of transition from cangrelor to oral P2Y12 inhibitor administration was 0.1 (-0.5-21.0 hours) for patients with CS. In multivariable modeling, chronic lung disease and the use of MCS and was associated with longer cangrelor infusions (defined as > 3.9 hours). Among cangrelor-treated patients with CS, 24.1% of these patients had a bleeding event, and 41.8% had a MACE event. After adjustment, a longer cangrelor infusion duration was associated with increased risk of bleeding (P < 0.05). CONCLUSIONS The median duration of cangrelor infusion was longer for patients presenting with CS. Use of MCS was associated with longer cangrelor infusion durations in patients with CS. Further work is needed to understand the pharmacodynamics of antiplatelet agents in patients with CS.
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Affiliation(s)
- Jennifer Rymer
- Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | | | | | | | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ajar Kochar
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | - Lawrence Ang
- University of California San Diego, San Diego, CA
| | - Richard Bach
- Washington University in St. Louis, St. Louis, MO
| | | | | | | | | | - W Schuyler Jones
- Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
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2
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Dangas G, Nicolas J, Harbich P, Huber K. Guideline recommendations for cangrelor should be upgraded: pros and cons. EUROINTERVENTION 2024; 20:e405-e407. [PMID: 38562067 PMCID: PMC10979382 DOI: 10.4244/eij-e-23-00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- George Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johny Nicolas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul Harbich
- 3rd Department of Medicine, Cardiology and Intensive Care Unit, Clinic Ottakring (former Wilhelminenhospital), Vienna, Austria
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Unit, Clinic Ottakring (former Wilhelminenhospital), Vienna, Austria
- Sigmund Freud University, Medical Faculty, Vienna, Austria
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3
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Buck MM, Barry CI, Montepara CA, Verlinden NJ. Platelet Function Testing to Guide Cangrelor Dosing in Patients with Temporary Mechanical Circulatory Support or as a Bridge to Procedure. Clin Appl Thromb Hemost 2024; 30:10760296241237228. [PMID: 38439661 PMCID: PMC10916455 DOI: 10.1177/10760296241237228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024] Open
Abstract
Cangrelor is a rapid-acting, intravenous P2Y12 inhibitor that can be used in patients after percutaneous coronary intervention who require mechanical circulatory support or as a bridge to procedure. We retrospectively reviewed adult patients who received platelet function testing (PFT) with the VerifyNow P2Y12 assay while on cangrelor from March 2021 through November 2022. All patients were initiated on 0.75 mcg/kg/min of cangrelor with P2Y12 reaction unit (PRU) values collected 12-24 h after initiation. Cangrelor doses were adjusted per protocol to maintain PRU values of 85-208. A total of 42 patients were included. Thirty-eight patients (90.5%) required temporary mechanical circulatory support while on cangrelor, and 4 patients (9.5%) received cangrelor as a bridge to procedure. The median cangrelor maintenance dose was 0.5 (interquartile range [IQR]: 0.375-0.75) mcg/kg/min, and the median time in therapeutic range with a PRU value between 85 and 208 was 66.6% (IQR: 39.6%-100%). No patients experienced stent thrombosis. A composite major adverse cardiovascular event occurred in 4 patients (9.5%), and major bleeding occurred in 16 patients (38.1%). Compared to empiric cangrelor dosing of 0.75 mcg/kg/min, PFT-guided cangrelor dose adjustment was associated with a median drug cost savings of $1605.60 (IQR: $0-4281.56). Utilizing PFT with cangrelor may allow for lower, individualized dosing while preventing stent thrombosis.
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Affiliation(s)
- Margaret M. Buck
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Chelsea I. Barry
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Courtney A. Montepara
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
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4
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Tang S, Xu L, Li H, Wu Z, Wen Q. Anticoagulants in adult extracorporeal membrane oxygenation: alternatives to standardized anticoagulation with unfractionated heparin. Eur J Clin Pharmacol 2023; 79:1583-1594. [PMID: 37740749 DOI: 10.1007/s00228-023-03568-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/14/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a vital technique for severe respiratory or heart failure patients. Bleeding and thrombotic events are common during ECMO and negatively impact patient outcomes. Unfractionated heparin is the primary anticoagulant, but its adverse effects limit its use, necessitating alternative anticoagulants. OBJECTIVE Review available alternative anticoagulants for adult ECMO patients. Explore potential novel anticoagulants for future ECMO use. Aim to reduce complications (bleeding and thrombosis) and improve safety and efficacy for critically ill ECMO patients. METHODS Comprehensive literature review of existing and emerging anticoagulants for ECMO. RESULTS Identified a range of alternative anticoagulants beyond unfractionated heparin. Evaluated their potential utility in mitigating ECMO-related complications. CONCLUSION Diverse anticoagulant options are available and under investigation for ECMO. These alternatives may enhance patient safety and outcomes during ECMO support. Further research and clinical studies are warranted to determine their effectiveness and safety profiles.
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Affiliation(s)
- Shu Tang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Liqing Xu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui Li
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhanshen Wu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiang Wen
- Institute of Clinical Pharmacology, Zhengzhou University, Zhengzhou, China
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5
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Cohan D, Uricchio MN, Konopka CI, Montepara CA, Verlinden NJ. Comparison of clinical outcomes with cangrelor plus aspirin versus oral dual antiplatelet therapy in patients supported with venoarterial extracorporeal membrane oxygenation. Artif Organs 2023; 47:1672-1677. [PMID: 37203212 DOI: 10.1111/aor.14590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/22/2023] [Accepted: 05/13/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Patients with refractory cardiogenic shock from an acute myocardial infarction may receive percutaneous coronary intervention (PCI) and require the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO). The purpose of this study was to compare bleeding and thrombotic events in patients treated with cangrelor plus aspirin versus oral dual antiplatelet therapy (DAPT) while supported with VA-ECMO. METHODS We conducted a retrospective review of patients who received PCI, were supported with VA-ECMO, and were treated with either cangrelor plus aspirin or oral DAPT from February 2016 through May 2021 at Allegheny General Hospital. The primary objective was the incidence of major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or greater. The incidence of thrombotic events was a secondary objective. RESULTS Thirty-seven patients were included, 19 in the cangrelor plus aspirin group, and 18 in the oral DAPT group. All the patients in the cangrelor group received a dose of 0.75 mcg/kg/min. Major bleeding occurred in 7 patients (36.8%) in the cangrelor group compared to 7 patients (38.9%) in the oral DAPT group (p = 0.90). No patient developed stent thrombosis. Two patients (10.5%) in the cangrelor group had a thrombotic event versus 3 patients (16.7%) in the oral DAPT group (p = 0.66). CONCLUSIONS Bleeding and thrombotic events were comparable between patients receiving cangrelor plus aspirin versus oral DAPT while on VA-ECMO.
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Affiliation(s)
- Dana Cohan
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, Virginia, USA
| | - Marissa N Uricchio
- Department of Pharmacy, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Chelsea I Konopka
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Courtney A Montepara
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Nathan J Verlinden
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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6
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De Luca L, Calabrò P, Chirillo F, Rolfo C, Menozzi A, Capranzano P, Menichelli M, Nicolini E, Mauro C, Trani C, Versaci F, Tomai F, Musumeci G, Di Mario C, Pepe M, Berti S, Cernetti C, Cirillo P, Maffeo D, Talanas G, Ferlini M, Contarini M, Lanzilotti V, Scherillo M, Tarantini G, Muraglia S, Rossini R, Bolognese L. Use of cangrelor in patients with acute coronary syndromes undergoing percutaneous coronary intervention: Study design and interim analysis of the ARCANGELO study. Clin Cardiol 2022; 45:913-920. [PMID: 35733352 PMCID: PMC9451664 DOI: 10.1002/clc.23878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The itAlian pRospective Study on CANGrELOr (ARCANGELO) was aimed to assess the safety of using cangrelor during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) in the daily practice. HYPOTHESIS The safety of cangrelor after the transition to oral P2Y12 inhibitors was evaluated as the incidence of bleeding outcomes in the 30 days following PCI according to postauthorization safety study guidelines. METHODS Adults with ACS who were treated with cangrelor in one of the 28 centers involved in the study. Patients who consented to participate were followed in the 30 days following their PCI. Bleedings (Bleeding Academic Research Consortium [BARC] classification), major adverse cardiac events (MACEs), and adverse events were recorded. The interim results at two-thirds of the enrollment period are presented. RESULTS A total of 17 bleedings were observed in the 320 patients who completed the study at this stage. All bleedings were classified as BARC Type 1-2, except for one case of Type 3a (vessel puncture site hematoma). Four patients experienced MACEs (2 acute myocardial infarctions, 1 sudden cardiac death, 1 noncardiovascular death due to respiratory distress, and multiorgan failure). None of the bleedings was rated as related to cangrelor. CONCLUSIONS The interim results of the ARCANGELO study provide a preliminary confirmation that the use of cangrelor on patients with ACS undergoing PCI is not associated with severe bleedings.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardiosciences, Division of CardiologyAzienda Ospedaliera San Camillo‐ForlaniniRomeItaly
| | - Paolo Calabrò
- U.O.C. Cardiologia Clinica con UTIC. A.O.R.N. Sant'Anna e San SebastianoCasertaItaly
| | - Fabio Chirillo
- U.O.C. Cardiologia Ospedale San BassianoBassano del Grappa (VI)Italy
| | - Cristina Rolfo
- S.C. Cardiologia Ospedale degli Infermi di Rivoli ASLTO3RivoliItaly
| | - Alberto Menozzi
- S.C. Cardiologia, Ospedale S. Andrea, ASL5 LiguriaLa SpeziaItaly
| | | | | | - Elisa Nicolini
- U.O. Cardiologia Interventisticastrutturale e pediatrica, Ospedali RiunitiAnconaItaly
| | - Ciro Mauro
- Cardiologia UTIC con emodinamica AORN Cardarelli NapoliiNapoliItaly
| | - Carlo Trani
- U.O.C. Interventistica Cardiologica e diagnostica invasiva Fondazione Policlinico Universitario A. Gemelli, IRCCSRomeItaly
| | | | | | | | - Carlo Di Mario
- Interventistica Cardiologica Strutturale A.O.U. CareggiFirenzeItaly
| | - Martino Pepe
- Cardiologia Universitaria A.O.U. Consorziale PoliclinicoBariItaly
| | - Sergio Berti
- Fondazione C.N.R. Reg. Toscana G. MonasterioPisaItaly
| | | | - Plinio Cirillo
- Dipartimento di Scienze Biomediche AvanzateCardiologia, A.O.U.P. “Federico II”NapoliItaly
| | - Diego Maffeo
- Cardiologia Emodinamica Fondazione PoliambulanzaBresciaItaly
| | - Giuseppe Talanas
- U.O.C. Cardiologia Clinica ed InterventisticaAzienda Ospedaliero‐Universitaria di SassariSassariItaly
| | - Marco Ferlini
- U.O.C. Cardiologia Fondazione IRCCS Policlinico San MatteoSan MatteoItaly
| | - Marco Contarini
- U.O.C. di Cardiologia con UTIC ed Emodinamica Ospedale Umberto I di Siracusa Azienda Sanitaria Provinciale diSiracusaItaly
| | | | - Marino Scherillo
- U.O.C. Cardiologia interventistica e UTIC Azienda Ospedaliera San PioBeneventoItaly
| | - Giuseppe Tarantini
- U.O.S.D. Emodinamica e Cardiologia Interventistica Azienda Ospedale UniversitàPadovaItaly
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7
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Rymer JA, Bhatt DL, Angiolillo DJ, Diaz M, Garratt KN, Waksman R, Edwards L, Tasissa G, Salahuddin K, El-Sabae H, Dell'Anna C, Davidson-Ray L, Washam JB, Ohman EM, Wang TY. Cangrelor Use Patterns and Transition to Oral P2Y 12 Inhibitors Among Patients With Myocardial Infarction: Initial Results From the CAMEO Registry. J Am Heart Assoc 2022; 11:e024513. [PMID: 35621210 PMCID: PMC9238709 DOI: 10.1161/jaha.121.024513] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background In clinical trials, cangrelor has been shown to reduce percutaneous coronary intervention–related ischemic complications without increasing major bleeding. This study was performed to examine cangrelor use and transition to oral P2Y12 inhibitors in routine clinical practice. Methods and Results The CAMEO (Cangrelor in Acute Myocardial Infarction: Effectiveness and Outcomes) registry is a multicenter, retrospective observational study of platelet inhibition strategies for patients with myocardial infarction undergoing percutaneous coronary intervention. In phase 1, data were collected on consecutive patients with myocardial infarction (n=482) treated with any P2Y12 inhibitor to understand cangrelor use by hospital. In phase 2, data were collected in a 2:1 (cangrelor‐: non‐cangrelor‐treated) ratio of patients with myocardial infarction (n=873). In phase 1, cangrelor use varied across hospitals (overall, 50.4% [range, 6.0%–100%]). Of patients receiving cangrelor in both phases (n=819), 3.3% received either the bolus or infusion only. Cangrelor was infused for a median of 121 (76–196) minutes; and 38.3% received an infusion for <2 hours. Most patients transitioned from cangrelor to ticagrelor (ticagrelor, 85.3%; clopidogrel, 9.5%; prasugrel, 5.2%). Many patients (16.4%) had a >1‐hour gap between cangrelor cessation and oral P2Y12 inhibitor initiation; this was highest among those transitioned to clopidogrel (56.6% versus 34.5% prasugrel versus 10.8% ticagrelor; P<0.001). Only 27.3% were dosed with cangrelor and transitioned to an oral P2Y12 inhibitor in a fashion consistent with the pivotal trials and US Food and Drug Administration label. Conclusions This multicenter registry demonstrated interhospital variability in how cangrelor was administered and transitioned to an oral P2Y12 inhibitor. These findings highlight opportunities for optimization of cangrelor dosing, infusion duration, and transition of care from the catheterization laboratory to the ward setting.
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Affiliation(s)
- Jennifer A Rymer
- Division of Cardiology Duke University Medical Center Durham NC.,Duke Clinical Research Institute Durham NC
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine Brigham and Women's HospitalHarvard Medical School Boston MA
| | | | | | | | - Ron Waksman
- Division of Cardiology MedStar Health Columbia MD
| | | | | | | | | | | | | | - Jeffrey B Washam
- Division of Clinical Pharmacology Duke University Medical Center Durham NC
| | - E Magnus Ohman
- Division of Cardiology Duke University Medical Center Durham NC.,Duke Clinical Research Institute Durham NC
| | - Tracy Y Wang
- Division of Cardiology Duke University Medical Center Durham NC.,Duke Clinical Research Institute Durham NC
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8
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Succar L, Lopez CN, Victor DW, Lindberg SA, Saharia A, Sheth S, Mobley CM. Perioperative cangrelor in patients with recent percutaneous coronary intervention undergoing liver transplantation: A case series. Pharmacotherapy 2022; 42:263-267. [PMID: 35075688 DOI: 10.1002/phar.2661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/25/2021] [Accepted: 12/06/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Management of dual antiplatelet therapy (DAPT) in the perioperative setting is challenging, particularly in complex patient populations, such as those with underlying coagulopathy and/or recent percutaneous coronary interventions. METHODS In this case series, we describe the perioperative use of cangrelor bridge therapy in two patients undergoing liver transplantation after recent coronary drug-eluting stent placement. OUTCOMES In both patient cases, cangrelor use as a P2Y12 bridge at a dose of 0.75 μg/kg/min was safe and effective. Both patients were successfully switched back to their oral DAPT regimen post-operatively without additive bleeding or thrombotic complications. CONCLUSION The use of cangrelor as bridge therapy in high-risk perioperative liver transplant patients appears to be a viable option when DAPT is warranted.
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Affiliation(s)
- Luma Succar
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Chelsea N Lopez
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - David W Victor
- J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas, USA.,Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Scott A Lindberg
- Department of Anesthesiology, Houston Methodist Hospital, Houston, Texas, USA
| | - Ashish Saharia
- J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA.,Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA.,Houston Methodist Academic Institute, Houston, Texas, USA
| | - Samar Sheth
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Constance M Mobley
- J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA.,Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA.,Houston Methodist Academic Institute, Houston, Texas, USA
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9
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Sullivan AE, Nanna MG, Wang TY, Bhatt DL, Angiolillo DJ, Mehran R, Banerjee S, Cantrell S, Jones WS, Rymer JA, Washam JB, Rao SV, Ohman EM. Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1550-1563. [PMID: 34620413 DOI: 10.1016/j.jacc.2021.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
Patients undergoing early surgery after coronary stent implantation are at increased risk for mortality from ischemic and hemorrhagic complications. The optimal antiplatelet strategy in patients who cannot discontinue dual antiplatelet therapy (DAPT) before surgery is unclear. Current guidelines, based on surgical and clinical characteristics, provide risk stratification for bridging therapy with intravenous antiplatelet agents, but management is guided primarily by expert opinion. This review summarizes perioperative risk factors to consider before discontinuing DAPT and reviews the data for intravenous bridging therapies. Published reports have included bridging options such as small molecule glycoprotein IIb/IIIa inhibitors (eptifibatide or tirofiban) and cangrelor, an intravenous P2Y12 inhibitor. However, optimal management of these complex patients remains unclear in the absence of randomized controlled data, without which an argument can be made both for and against the use of perioperative intravenous bridging therapy after discontinuing oral P2Y12 inhibitors. Multidisciplinary risk assessment remains a critical component of perioperative care.
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Affiliation(s)
- Alexander E Sullivan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA. https://twitter.com/aesullivan37
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tracy Y Wang
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Deepak L Bhatt
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Roxana Mehran
- Division of Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Subhash Banerjee
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, North Carolina, USA
| | - W Schuyler Jones
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer A Rymer
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Sunil V Rao
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - E Magnus Ohman
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.
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10
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De Luca L, Steg PG, Bhatt DL, Capodanno D, Angiolillo DJ. Cangrelor: Clinical Data, Contemporary Use, and Future Perspectives. J Am Heart Assoc 2021; 10:e022125. [PMID: 34212768 PMCID: PMC8403274 DOI: 10.1161/jaha.121.022125] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cangrelor is the only currently available intravenous platelet P2Y12 receptor inhibitor. It is characterized by potent, predictable, and rapidly reversible antiplatelet effects. Cangrelor has been tested in the large CHAMPION (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) program, where it was compared with different clopidogrel regimens, and it is currently indicated for use in patients with coronary artery disease undergoing percutaneous coronary intervention. However, the uptake of cangrelor use varies across the globe and may also include patients with profiles different from those enrolled in the registration trials. These observations underscore the need to fully examine the safety and efficacy of cangrelor in postregistration studies. There are several ongoing and planned studies evaluating the use of cangrelor in real‐world practice which will provide important insights to this extent. The current article provides a review on the pharmacology, clinical studies, contemporary use of cangrelor in real‐world practice, a description of ongoing studies, and futuristic insights on potential strategies on how to improve outcomes of patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology Department of Cardiosciences Azienda Ospedaliera San Camillo-Forlanini Roma Italy
| | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148 AP-HPHôpital BichatUniversité de Paris France.,NHLI (National Heart and Lung Institute)Imperial CollegeICMS Royal Brompton Hospital London United Kingdom
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center Harvard Medical School Boston MA
| | - Davide Capodanno
- Division of Cardiology A.O.U. Policlinico "G. Rodolico-San Marco" University of Catania Catania Italy
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11
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van der Sangen NMR, Cheung HY, Verouden NJW, Appelman Y, Beijk MAM, Claessen BEPM, Delewi R, Knaapen P, Lemkes JS, Nap A, Vis MM, Kikkert WJ, Henriques JPS. Cangrelor Use in Routine Practice: A Two-Center Experience. J Clin Med 2021; 10:2829. [PMID: 34206905 PMCID: PMC8269409 DOI: 10.3390/jcm10132829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 12/04/2022] Open
Abstract
Cangrelor is the first and only intravenous P2Y12-inhibitor and is indicated when (timely) administration of an oral P2Y12 inhibitor is not feasible in patients undergoing percutaneous coronary intervention (PCI). Our study evaluated the first years of cangrelor use in two Dutch tertiary care centers. Cangrelor-treated patients were identified using a data-mining algorithm. The cumulative incidences of all-cause death, myocardial infarction, definite stent thrombosis and major bleeding at 48 h and 30 days were assessed using Kaplan-Meier estimates. Predictors of 30-day mortality were identified using uni- and multivariable Cox regression models. Between March 2015 and April 2021, 146 patients (median age 63.7 years, 75.3% men) were treated with cangrelor. Cangrelor was primarily used in ST-segment elevation myocardial infarction (STEMI) patients (84.2%). Approximately half required cardiopulmonary resuscitation (54.8%) or mechanical ventilation (48.6%). The cumulative incidence of all-cause death was 11.0% and 25.3% at 48 h and 30 days, respectively. Two cases (1.7%) of definite stent thrombosis, both resulting in myocardial infarction, occurred within 30 days, but after 48 h. No other cases of recurrent myocardial infarction transpired within 30 days. Major bleeding occurred in 5.6% and 12.5% of patients within 48 h and 30 days, respectively. Cardiac arrest at presentation was an independent predictor of 30-day mortality (adjusted hazard ratio 5.20, 95%-CI: 2.10-12.9, p < 0.01). Conclusively, cangrelor was used almost exclusively in STEMI patients undergoing PCI. Even though cangrelor was used in high-risk patients, its use was associated with a low rate of stent thrombosis.
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Affiliation(s)
- Niels M. R. van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Ho Yee Cheung
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Niels J. W. Verouden
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Marcel A. M. Beijk
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Bimmer E. P. M. Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Jorrit S. Lemkes
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - M. Marije Vis
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Wouter J. Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, 1091 AC Amsterdam, The Netherlands
| | - José P. S. Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
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Siciliano R, Canonico ME, Talanas G, Saba PS, Parodi G. Cangrelor-supported primary percutaneous coronary intervention in a patient with cardiogenic shock due to left main acute occlusion. J Cardiovasc Med (Hagerstown) 2021; 21:616-617. [PMID: 32520863 DOI: 10.2459/jcm.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Roberta Siciliano
- Clinical and Interventional Cardiology Unit, Sassari University Hospital, Sassari, Italy
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Katz A, Lewis TC, Arnouk S, Altshuler D, Papadopoulos J, Toy B, Smith DE, Merchan C. Clinical Use of Cangrelor After Percutaneous Coronary Intervention in Patients Requiring Mechanical Circulatory Support. Ann Pharmacother 2021; 55:1215-1222. [PMID: 33567855 DOI: 10.1177/1060028021994621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients with cardiogenic shock after percutaneous coronary intervention (PCI) may require mechanical circulatory support (MCS). The combination of dual antiplatelet therapy with cangrelor and continuous anticoagulation required for MCS may increase the risk of bleeding. OBJECTIVE The objective of the study is to describe the complications and outcomes of patients who received cangrelor during MCS following PCI. METHODS This is a single-center, retrospective, observational case series of 17 patients who received cangrelor while on MCS from June 2017 to September 2019. RESULTS In a case series of 17 patients, 8 patients (47%) were supported with an Impella device and 4 patients (24%) with venoarterial (VA) extracorporeal membrane oxygenation (ECMO); 5 required (29%) concomitant VA ECMO and Impella support in the setting of cardiogenic shock. All patients received triple antithrombotic therapy with aspirin, heparin, and cangrelor. Cangrelor was commonly initiated at a median dose of 0.75 (range 0.5-4) µg/kg/min. Cangrelor dose adjustments included changes in increments up to 0.25 µg/kg/min with review of P2Y12 levels. A total of 10 patients (59%) experienced a bleeding event, most commonly located at the peripheral cannulation site (40%) and in the gastrointestinal tract (30%). Seven (70%) and 3 (30%) of the bleeding complications were classified as major and minor, respectively. No patient developed in-stent thrombosis during the hospitalization; 14 (82%) patients survived their MCS course. CONCLUSION AND RELEVANCE This case series suggests that cangrelor doses less than 0.75 µg/kg/min may be beneficial. Larger studies should evaluate alternative dosing regimens.
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Grimfjärd P, Lagerqvist B, Erlinge D, Varenhorst C, James S. Clinical use of cangrelor: nationwide experience from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 5:151-157. [PMID: 30698669 DOI: 10.1093/ehjcvp/pvz002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/28/2018] [Accepted: 01/13/2019] [Indexed: 01/06/2023]
Abstract
AIMS This nationwide study aimed to analyse the first 2 years of routine clinical use of cangrelor in all Swedish patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS This observational Swedish Coronary Angiography and Angioplasty Registry (SCAAR) study identified 915 cangrelor-treated patients. As 899 were ST-segment elevation myocardial infarction (STEMI)-patients undergoing primary PCI, we decided to exclude all non-STEMI patients (n = 16) from the following analysis. We then identified all primary PCI patients, January 2016 to January 2018 (n = 10 816). Excluding hospitals without cangrelor use, tailoring time frames from first cangrelor use per hospital, patients treated with cangrelor (n = 899) were compared with those without cangrelor treatment (n = 4614). A separate analysis was performed for cardiac arrest STEMI patients (n = 273). Cangrelor-use in primary PCI varied greatly between hospitals (4-36%, mean 16%). At variance with randomized trials, cangrelor was used nearly exclusively in STEMI, often with cardiac arrest (19%). Cangrelor was combined with ticagrelor in two-thirds of patients, among which >50% was prehospital. Cangrelor was used more frequently in high-risk patients: left main PCI, thrombus aspiration, and cardiac arrest. Despite cangrelor being used in more high-risk patients, crude definite stent thrombosis rates at 30 days were low and similar in cangrelor (0.7%) and non-cangrelor treated patients (0.8%). CONCLUSION Cangrelor was used nearly exclusively in primary PCI STEMI patients, predominantly with ticagrelor. Despite being used in very high-risk patients, often with cardiac arrest, cangrelor treatment was associated with low stent thrombosis rates.
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Affiliation(s)
- Per Grimfjärd
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden.,Department of Cardiology, Västerås Hospital, Sigtunagatan, 721 89 Västerås, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Box 117, Skåne University Hospital, Block EA, 22100 Lund, Sweden
| | - Christoph Varenhorst
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden.,Pfizer AB Sverige, Vetenskapsvägen 10, Sollentuna, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden
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Abstract
Inadequate antiplatelet effects can result in substantial morbidity and mortality in patients with acute coronary syndrome and percutaneous coronary intervention (PCI). Cangrelor is a rapid onset and potent intravenous P2Y12 inhibitor that has been shown in large randomized controlled trials to reduce periprocedural complications for PCI compared with clopidogrel, the most commonly used P2Y12 inhibitor. Cangrelor should be considered in the setting of PCI to reduce the risk of periprocedural complications such as myocardial infarction, repeat coronary revascularization and stent thrombosis in patients not yet treated with another P2Y12 inhibitor or glycoprotein IIb/IIIa inhibitor. In this review, the importance of adequate P2Y12 inhibition, cangrelor's pharmacology and clinical profiles, and future directions for the cangrelor are discussed.
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Affiliation(s)
- Kent Y Feng
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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Franchi F, Rollini F, Rivas A, Wali M, Briceno M, Agarwal M, Shaikh Z, Nawaz A, Silva G, Been L, Smairat R, Kaufman M, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Platelet Inhibition With Cangrelor and Crushed Ticagrelor in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circulation 2020; 139:1661-1670. [PMID: 30630341 DOI: 10.1161/circulationaha.118.038317] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The platelet inhibitory effects induced by oral P2Y12 receptor antagonists are delayed in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (P-PCI). In turn, this leads to a gap in platelet inhibition, exposing patients to an increased risk of early thrombotic complications and underscoring the need to define strategies associated with more effective platelet inhibition in the peri-primary percutaneous coronary intervention period. Cangrelor is an intravenous P2Y12 inhibitor with prompt and potent antiplatelet effects. However, to date, there are limited data on the effects of cangrelor used in combination with ticagrelor in patients undergoing primary percutaneous coronary intervention. Moreover, questions have emerged on the potential for drug-drug interactions during the transition from cangrelor to oral P2Y12 inhibitors. METHODS This was a prospective, randomized, double-blind, placebo-controlled pharmacodynamic study conducted in patients undergoing primary percutaneous coronary intervention (n=50) who were randomized to treatment with either cangrelor or matching placebo (bolus followed by 2-hour infusion). All patients received ticagrelor 180-mg loading dose administered as crushed tablets at the time of cangrelor/placebo bolus administration. Pharmacodynamic analyses were performed at 8 time points. Pharmacodynamic effects were measured as P2Y12 reaction units by VerifyNow and platelet reactivity index by vasodilator-stimulated phosphoprotein. RESULTS Compared with placebo, cangrelor was associated with reduced P2Y12 reaction units as early as 5 minutes after bolus, which persisted during the entire duration of drug infusion, including at 30 minutes (63 [32-93] versus 214 [183-245]; mean difference, 152 [95% CI, 108-195]; P<0·001; primary end point). Parallel findings were shown with platelet reactivity index. Accordingly, high on-treatment platelet reactivity rates were reduced with cangrelor. After discontinuation of cangrelor/placebo infusion, there were no differences in levels of platelet reactivity between groups, ruling out a drug-drug interaction when cangrelor and ticagrelor are concomitantly administered. CONCLUSIONS In patients undergoing primary percutaneous coronary intervention, cangrelor is an effective strategy to bridge the gap in platelet inhibition associated with the use of oral P2Y12 inhibition induced by ticagrelor. Ticagrelor can be administered as a crushed formulation concomitantly with cangrelor without any apparent drug-drug interaction. The clinical implications of these pharmacodynamic findings warrant investigation in an adequately powered clinical trial. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT03247738.
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Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Mustafa Wali
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Maryuri Briceno
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Malhar Agarwal
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Zubair Shaikh
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Ahmed Nawaz
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Gabriel Silva
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Ramez Smairat
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Marc Kaufman
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Theodore A Bass
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
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Majithia A, Bhatt DL. Novel Antiplatelet Therapies for Atherothrombotic Diseases. Arterioscler Thromb Vasc Biol 2019; 39:546-557. [PMID: 30760019 PMCID: PMC6445601 DOI: 10.1161/atvbaha.118.310955] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/20/2019] [Indexed: 01/03/2023]
Abstract
Antiplatelet therapies are an essential tool to reduce the risk of developing clinically apparent atherothrombotic disease and are a mainstay in the therapy of patients who have established cardiovascular, cerebrovascular, and peripheral artery disease. Strategies to intensify antiplatelet regimens are limited by concomitant increases in clinically significant bleeding. The development of novel antiplatelet therapies targeting additional receptor and signaling pathways, with a focus on maintaining antiplatelet efficacy while preserving hemostasis, holds tremendous potential to improve outcomes among patients with atherothrombotic diseases.
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Affiliation(s)
- Arjun Majithia
- From the Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- From the Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
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Cangrelor in cardiogenic shock and after cardiopulmonary resuscitation: A global, multicenter, matched pair analysis with oral P2Y 12 inhibition from the IABP-SHOCK II trial. Resuscitation 2019; 137:205-212. [PMID: 30790690 DOI: 10.1016/j.resuscitation.2019.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/01/2019] [Accepted: 02/11/2019] [Indexed: 01/06/2023]
Abstract
AIMS Cangrelor has a potentially favorable pharmacodynamic profile in cardiogenic shock (CS). We aimed to evaluate the clinical course of CS patients undergoing percutaneous coronary intervention (PCI) treated with cangrelor. METHODS AND RESULTS We retrospectively identified 136 CS patients treated with cangrelor. Patients were 1:1 matched to CS patients from the IABP-SHOCK II trial not receiving cangrelor by age, sex, cardiac arrest, type of myocardial infarction, culprit lesion, glycoprotein IIb/IIIa inhibitor, and oral P2Y12-receptor inhibitor and followed-up for 12 months. The study cohort consisted of 88 matched pairs. Thirty-day and 12-month mortality was 29.5% and 34.1% in cangrelor-treated patients and 36.4% and 47.1% in control group (P = 0.34 and P = 0.08, respectively). The rate of definite acute stent thrombosis was 2.3% in both groups. Moderate and severe bleeding events occurred in 21.6% in the cangrelor and 19.3% in the control group (P = 0.71). Patients treated with cangrelor more frequently experienced ≥1 TIMI flow grade improvement during PCI (92.9% vs. 81.2%, P = 0.02). CONCLUSION Cangrelor treatment was associated with similar bleeding risk and significantly better TIMI flow improvement compared with oral P2Y12 inhibitors in CS patients undergoing PCI. The use of cangrelor in CS offers a potentially safe and effective antiplatelet option and should be evaluated in randomized trials.
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Lozano I, Rondan J, Vegas JM, Segovia E. Cangrelor or Abciximab as First Choice in Cardiogenic Shock. JACC Cardiovasc Interv 2019; 10:2467-2468. [PMID: 29217012 DOI: 10.1016/j.jcin.2017.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
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Vaduganathan M, Qamar A, Badreldin HA, Faxon DP, Bhatt DL. Reply: Cangrelor or Abciximab as First Choice in Cardiogenic Shock. JACC Cardiovasc Interv 2019; 10:2468-2469. [PMID: 29217013 DOI: 10.1016/j.jcin.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/03/2017] [Indexed: 11/18/2022]
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Cangrelor Induces More Potent Platelet Inhibition without Increasing Bleeding in Resuscitated Patients. J Clin Med 2018; 7:jcm7110442. [PMID: 30445678 PMCID: PMC6262477 DOI: 10.3390/jcm7110442] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 12/31/2022] Open
Abstract
Dual antiplatelet therapy is the standard of care for patients with myocardial infarction (MI), who have been resuscitated and treated with therapeutic hypothermia (TH). We compare the antiplatelet effect and bleeding risk of intravenous cangrelor to oral P2Y12-inhibitors in patients with MI receiving TH in a prospective comparison of two matched patient cohorts. Twenty-five patients within the CANGRELOR cohort were compared to 17 patients receiving oral P2Y12-inhibitors. CANGRELOR group (NCT03445546) and the ORAL P2Y12 Group (NCT02914795) were registered at clinicaltrials.gov. Platelet function testing was performed using light-transmittance aggregometry and monitored for 4 days. P2Y12-inhibition was stronger in CANGRELOR compared to ORAL P2Y12 (adenosine diphosphate (ADP) (area under the curve (AUC)) 26.0 (5.9–71.6) vs. 160.9 (47.1–193.7)) at day 1. This difference decreased over the following days as more patients were switched from CANGRELOR to oral P2Y12-inhibitor treatment. There was no difference in the effect of aspirin between the two groups. We did not observe significant differences with respect to thrombolysis in myocardial infarction (TIMI) or Bleeding Academic Research Consortium (BARC) classified bleedings, number of blood transfusions or drop in haemoglobin B (Hb) or hematocrit (Hct) over time. Cangrelor treatment is not only feasible and effective in resuscitated patients, but also inhibited platelet function more effectively than orally administered P2Y12-inhibitors without an increased event rate for bleeding.
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