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Silverio A, Bellino M, Scudiero F, Attisano T, Baldi C, Catalano A, Centore M, Cesaro A, Di Maio M, Esposito L, Granata G, Maiellaro F, Muraca I, Musumeci G, Parodi G, Personeni D, Valenti R, Vecchione C, Calabrò P, Galasso G. Intravenous antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention : A report from the INVEST-STEMI group. J Thromb Thrombolysis 2024; 57:757-766. [PMID: 38615155 DOI: 10.1007/s11239-024-02970-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 04/15/2024]
Abstract
The use of intravenous antiplatelet therapy during primary percutaneous coronary intervention (PPCI) is not fully standardized. The aim is to evaluate the effectiveness and safety of periprocedural intravenous administration of cangrelor or tirofiban in a contemporary ST-segment elevation myocardial infarction (STEMI) population undergoing PPCI. This was a multicenter prospective cohort study including consecutive STEMI patients who received cangrelor or tirofiban during PPCI at seven Italian centers. The primary effectiveness measure was the angiographic evidence of thrombolysis in myocardial infarction (TIMI) flow < 3 after PPCI. The primary safety outcome was the in-hospital occurrence of BARC (Bleeding Academic Research Consortium) 2-5 bleedings. The study included 627 patients (median age 63 years, 79% males): 312 received cangrelor, 315 tirofiban. The percentage of history of bleeding, pulmonary edema and cardiogenic shock at admission was comparable between groups. Patients receiving cangrelor had lower ischemia time compared to tirofiban. TIMI flow before PPCI and TIMI thrombus grade were comparable between groups. At propensity score-weighted regression analysis, the risk of TIMI flow < 3 was significantly lower in patients treated with cangrelor compared to tirofiban (adjusted OR: 0.40; 95% CI: 0.30-0.53). The risk of BARC 2-5 bleeding was comparable between groups (adjusted OR:1.35; 95% CI: 0.92-1.98). These results were consistent across multiple prespecified subgroups, including subjects stratified for different total ischemia time, with no statistical interaction. In this real-world multicenter STEMI population, the use of cangrelor was associated with improved myocardial perfusion assessed by coronary angiography after PPCI without increasing clinically-relevant bleedings compared to tirofiban.
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Affiliation(s)
- Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy.
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy
| | - Fernando Scudiero
- Cardiology Unit, Medical Sciences Departement, ASST Bergamo Est, Seriate, Bergamo, Italy
| | - Tiziana Attisano
- Interventional Cardiology Unit, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Cesare Baldi
- Interventional Cardiology Unit, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Angelo Catalano
- Cardiology Unit, Hospital Maria SS. Addolorata, Eboli, Italy
| | - Mario Centore
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy
- Cardiology Unit, Hospital Maria SS. Addolorata, Eboli, Italy
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy
| | - Luca Esposito
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Giovanni Granata
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy
| | | | - Iacopo Muraca
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Giuseppe Musumeci
- Cardiology Department, Azienda Ospedaliera Ordine Mauriziano Umberto I, Turin, Italy
| | - Guido Parodi
- Cardiology Unit, Department of Medicine, Lavagna Hospital, Lavagna, Italy
| | - Davide Personeni
- Cardiology Unit, Medical Sciences Departement, ASST Bergamo Est, Seriate, Bergamo, Italy
| | - Renato Valenti
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy
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Rymer J, Alhanti B, Kemp S, Bhatt DL, Kochar A, Angiolillo DJ, Diaz M, Garratt KN, Wimmer NJ, Waksman R, Kirtane AJ, Ang L, Bach R, Barker C, Jenkins R, Basir MB, Sullivan A, El-Sabae H, Brothers L, Ohman EM, Jones WS, Washam JB, Wang TY. Risk of Bleeding Among Cangrelor-Treated Patients Administered Upstream P2Y 12 Inhibitor Therapy: The CAMEO Registry. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101202. [PMID: 39132213 PMCID: PMC11308101 DOI: 10.1016/j.jscai.2023.101202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 08/13/2024]
Abstract
Background Little is known about the bleeding risk associated with cangrelor use in patients with myocardial infarction (MI) who are exposed to an oral P2Y12 inhibitor before coronary angiography. Methods Cangrelor in Acute MI: Effectiveness and Outcomes (CAMEO) is an observational registry studying platelet inhibition for patients with MI. Upstream oral P2Y12 inhibition was defined as receipt of an oral P2Y12 inhibitor within 24 hours before hospitalization or in-hospital before angiography. Among cangrelor-treated patients, we compared bleeding after cangrelor use through 7 days postdischarge between patients with and without upstream oral P2Y12 inhibitor exposure. Results Among 1802 cangrelor-treated patients with MI, 385 (21.4%) received upstream oral P2Y12 inhibitor treatment. Of these, 101 patients (33.8%) started cangrelor within 1 hour, 103 (34.4%) between 1 and 3 hours, and 95 (31.8%), >3 hours after in-hospital oral P2Y12 inhibitor administration; the remaining received an oral P2Y12 inhibitor before hospitalization. There was no statistically significant difference in rates of bleeding among cangrelor-treated patients with and without upstream oral P2Y12 inhibitor exposure (6.5% vs 8.8%; adjusted odds ratio [OR], 0.62; 95% CI, 0.38-1.01). Bleeding was observed in 5.0%, 10.7%, and 3.2% of patients treated with cangrelor <1, 1 to 3, and >3 hours after the last oral PY12 inhibitor dose, respectively; bleeding rates were not statistically different between groups (1-3 hours vs <1 hour: adjusted OR, 2.70; 95% CI, 0.87-8.32; >3 hours vs <1 hour: adjusted OR, 0.65; 95% CI, 0.15-2.85). Conclusions Bleeding risk was not observed to be significantly higher after cangrelor treatment in patients with and without upstream oral P2Y12 inhibitor exposure.
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Affiliation(s)
- Jennifer Rymer
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina
| | - Steven Kemp
- Duke Clinical Research Institute, Durham, North Carolina
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York
| | - Ajar Kochar
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York
| | - Dominick J. Angiolillo
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | | | | | | | - Ron Waksman
- Washington MedStar, Washington, District of Columbia
| | - Ajay J. Kirtane
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Lawrence Ang
- Division of Cardiovascular Medicine, University of California San Diego, San Diego, California
| | - Richard Bach
- Cardiovascular Division, Washington University in St. Louis, St. Louis, Missouri
| | - Colin Barker
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
| | | | | | - Alex Sullivan
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Leo Brothers
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - W. Schuyler Jones
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Tracy Y. Wang
- Duke Clinical Research Institute, Durham, North Carolina
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Droppa M, Geisler T. Optimal Antithrombotic Strategies in Cardiogenic Shock. J Clin Med 2024; 13:277. [PMID: 38202284 PMCID: PMC10779586 DOI: 10.3390/jcm13010277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/22/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
Cardiogenic shock (CS) represents a critical condition with a high mortality rate. The most common cause of CS is coronary artery disease, and patients typically present with myocardial infarction, necessitating immediate treatment through percutaneous coronary intervention (PCI) and often requiring mechanical circulatory support. CS is associated with a prothrombotic situation, while on the other hand, there is often a significant risk of bleeding. This dual challenge complicates the selection of an optimal antithrombotic strategy. The choice of antithrombotic agents must be personalized, taking into consideration all relevant conditions. Repeated risk assessment, therapeutic monitoring, and adjusting antithrombotic therapy are mandatory in these patients. This review article aims to provide an overview of the current evidence and practical guidance on antithrombotic strategies in the context of CS.
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Affiliation(s)
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital of Tuebingen, 72076 Tuebingen, Germany
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Mostafa MR, Eid MM, Awad AK, Takla A, Hassan AR, Katamesh BE, AlBarakat MM, Ziada AR, Mohamed S, Al-Azizi KM, Goldsweig AM. Safety and Efficacy of Cangrelor in Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. Am J Cardiovasc Drugs 2024; 24:71-81. [PMID: 37995040 DOI: 10.1007/s40256-023-00616-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Cangrelor is a potent intravenous non-thienopyridine P2Y12 inhibitor. We conducted a network meta-analysis to study the efficacy and safety of cangrelor as compared with the oral P2Y12 inhibition, clopidogrel, or placebo in acute coronary syndromes. METHODS This meta-analysis followed the Cochrane collaboration guidelines and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols. Outcomes of interest included all-cause mortality, myocardial infarction, stent thrombosis, target vessel revascularization, major bleeding, minor bleeding, and the need for blood transfusion. RESULTS The analysis was comprised of 6 studies including 26,444 patients treated with cangrelor, clopidogrel, or placebo. There were no statistically significant differences in the incidence of all-cause mortality, myocardial infarction, stent thrombosis, target vessel revascularization, or major bleeding. Cangrelor was associated with a higher risk of minor bleeding than clopidogrel or placebo, with no difference in requiring blood transfusion. CONCLUSION Cangrelor has comparable outcomes to clopidogrel in patients with acute coronary syndromes and can be used as a reliable alternative in this population.
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Affiliation(s)
| | | | - Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Andrew Takla
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | | | | | - Majd M AlBarakat
- Faculty of Medicine, Jordan University of Science and Technology, Amman, Jordan
| | | | | | - Karim M Al-Azizi
- Baylor Scott and White Health-The Heart Hospital, Plano, TX, USA
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA, USA
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Spagnolo M, Angiolillo DJ, Capodanno D. Evaluating the pharmacokinetic and pharmacodynamic impact of different modes of ticagrelor administration. Expert Opin Drug Metab Toxicol 2023; 19:769-784. [PMID: 37849294 DOI: 10.1080/17425255.2023.2272595] [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: 07/22/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Alternative administration modes for oral P2Y12 inhibitors, particularly ticagrelor, have emerged as a potential alternative to overcome the limitations associated with the delayed onset of action of these drugs in patients who are unable to swallow or with impaired absorption. AREAS COVERED This comprehensive literature review aims to provide an overview of the current state of knowledge on the pharmacokinetics and administration modes of ticagrelor, including factors that may affect its action. It also compares the pharmacokinetics of ticagrelor with that of other drugs with similar uses to provide a comprehensive understanding of the potential advantages and limitations of different modalities of P2Y12 administration. For this purpose, Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov were searched from database inception to July 2023. EXPERT OPINION Among the different alternatives, crushed formulations, especially for ticagrelor, have emerged as the most promising option, showing early and robust platelet inhibition. However, important questions remain unanswered, such as the comparative clinical benefits of crushed ticagrelor versus standard administration, the cost-effectiveness of alternative modes compared to intravenous P2Y12 inhibitors such as cangrelor, and the important limitations associated with the concomitant use of opioids, who have been proven to impair even the action of crushed ticagrelor.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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Pepe M, Carulli E, Larosa C, Napoli G, Nestola PL, Carella MC, Giordano S, Tritto R, Bartolomucci F, Cirillo P, Zoccai GB, Giordano A, Ciccone MM. Comparative effectiveness of Cangrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: an observational investigation from the M.O.Ca. registry. Sci Rep 2023; 13:10685. [PMID: 37393369 PMCID: PMC10314899 DOI: 10.1038/s41598-023-37084-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/15/2023] [Indexed: 07/03/2023] Open
Abstract
Cangrelor, the first intravenous P2Y12 inhibitor (P2Y12-I), has been approved on the basis of three large RCTs from the CHAMPION program which nevertheless have been criticized for the low bleeding risk of the enrolled patients, the large quote of chronic coronary syndromes, and the use of Clopidogrel as control arm even in the setting of acute coronary syndromes (ACS). We sought to investigate, in the setting of ACS, the comparative performance of Cangrelor in terms of in-hospital ischemic and haemorrhagic outcomes compared with the current gold-standard of oral P2Y12-I. The study retrospectively enrolled 686 consecutive patients admitted to the Divisions of Cardiology of Policlinico of Bari and L. Bonomo Hospital of Andria for ACS and treated with percutaneous coronary intervention. The study population was divided according to the P2Y12-I treatment strategy in two groups: patients given an oral P2Y12-I and patients receiving Cangrelor in the cath lab followed by an oral P2Y12-I. Clinical endpoints included death, ischemic and bleeding events occurring during hospital stay. Cangrelor treated patients presented higher clinical risk profile at presentation and faced higher death rate. However, after PS matching, in-hospital mortality resulted comparable between the groups and Cangrelor use was associated with reduced in-hospital definite stent thrombosis (p = 0.03). Data from our real-world registry highlight that, in the setting of ACS, Cangrelor is prevalently used in patients with very challenging clinical presentations. The adjusted analysis provides for the first time promising data on stent thrombosis reduction associated with Cangrelor use.
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Affiliation(s)
- Martino Pepe
- Division of Cardiology, Department of Interdisciplinary Medicine (D.I.M.), University of Bari "Aldo Moro", Bari, Italy.
- Cardiovascular Diseases Section, Cardiothoracic Department (DAI), University of Bari, Polyclinic of Bari, P.zza Giulio Cesare 11, 70124, Bari, Italy.
| | - Eugenio Carulli
- Division of Cardiology, Department of Interdisciplinary Medicine (D.I.M.), University of Bari "Aldo Moro", Bari, Italy
| | - Claudio Larosa
- Division of Cardiology, Lorenzo Bonomo Hospital, Andria, Italy
| | - Gianluigi Napoli
- Division of Cardiology, Department of Interdisciplinary Medicine (D.I.M.), University of Bari "Aldo Moro", Bari, Italy
| | - Palma Luisa Nestola
- Division of Cardiology, Department of Interdisciplinary Medicine (D.I.M.), University of Bari "Aldo Moro", Bari, Italy
| | - Maria Cristina Carella
- Division of Cardiology, Department of Interdisciplinary Medicine (D.I.M.), University of Bari "Aldo Moro", Bari, Italy
| | - Salvatore Giordano
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Rocco Tritto
- Division of Cardiology, Department of Interdisciplinary Medicine (D.I.M.), University of Bari "Aldo Moro", Bari, Italy
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Arturo Giordano
- Invasive Cardiology Unit, "Pineta Grande" Hospital, Castel Volturno, Caserta, Italy
| | - Marco Matteo Ciccone
- Division of Cardiology, Department of Interdisciplinary Medicine (D.I.M.), University of Bari "Aldo Moro", Bari, Italy
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Thim T, Jakobsen L, Jensen RV, Støttrup N, Eftekhari A, Grove EL, Larsen SB, Sørensen JT, Carstensen S, Amiri S, Veien KT, Christiansen EH, Terkelsen CJ, Maeng M, Kristensen SD. Real-World Experience with Cangrelor as Adjuvant to Percutaneous Coronary Intervention: A Single-Centre Observational Study. Cardiol Res Pract 2023; 2023:3197512. [PMID: 37361000 PMCID: PMC10289876 DOI: 10.1155/2023/3197512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/03/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
Background Reversible P2Y12 inhibition can be obtained with cangrelor administered intravenously. More experience with cangrelor use in acute PCI with unknown bleeding risk is needed. Objectives To describe real-world use of cangrelor including patient and procedure characteristics and patient outcomes. Methods We performed a single-centre, retrospective, and observational study including all patients treated with cangrelor in relation to percutaneous coronary intervention at Aarhus University Hospital during the years 2016, 2017, and 2018. We recorded procedure indication and priority, the indications for cangrelor use, and patient outcomes within the first 48 hours after initiation of cangrelor treatment. Results We treated 991 patients with cangrelor in the study period. Of these, 869 (87.7%) had an acute procedure priority. Among acute procedures, patients were mainly treated for STEMI (n = 723) and the remaining were treated for cardiac arrest and acute heart failure. Use of oral P2Y12 inhibitors prior to percutaneous coronary intervention was rare. Fatal bleeding events (n = 6) were only observed among patients undergoing acute procedures. Stent thrombosis was observed in two patients receiving acute treatment for STEMI. Thus, cangrelor can be used in relation to PCI under acute circumstances with advantages in terms of clinical management. The benefits and risks, in terms of patient outcomes, should ideally be assessed in randomized trials.
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Affiliation(s)
- Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Lars Jakobsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Nicolaj Støttrup
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | | | - Steen Carstensen
- Emergency Department, Bispebjerg University Hospital, Bispebjerg, Denmark
| | - Sahar Amiri
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Alagna G, Mazzone P, Contarini M, Andò G. Dual Antiplatelet Therapy with Parenteral P2Y 12 Inhibitors: Rationale, Evidence, and Future Directions. J Cardiovasc Dev Dis 2023; 10:jcdd10040163. [PMID: 37103042 PMCID: PMC10144071 DOI: 10.3390/jcdd10040163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 04/28/2023] Open
Abstract
Dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and an inhibitor of the platelet P2Y12 receptor for ADP, remains among the most investigated treatments in cardiovascular medicine. While a substantial amount of research initially stemmed from the observations of late and very late stent thrombosis events in the first-generation drug-eluting stent (DES) era, DAPT has been recently transitioning from a purely stent-related to a more systemic secondary prevention strategy. Oral and parenteral platelet P2Y12 inhibitors are currently available for clinical use. The latter have been shown to be extremely suitable in drug-naïve patients with acute coronary syndrome (ACS), mainly because oral P2Y12 inhibitors are associated with delayed efficacy in patients with STEMI and because pre-treatment with P2Y12 inhibitors is discouraged in NSTE-ACS, and in patients with recent DES implantation and in need of urgent cardiac and non-cardiac surgery. More definitive evidence is needed, however, about optimal switching strategies between parenteral and oral P2Y12 inhibitors and about newer potent subcutaneous agents that are being developed for the pre-hospital setting.
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Affiliation(s)
- Giulia Alagna
- Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy
| | - Paolo Mazzone
- Cardiology Unit, "Umberto I" Hospital, 96100 Siracusa, Italy
| | - Marco Contarini
- Cardiology Unit, "Umberto I" Hospital, 96100 Siracusa, Italy
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy
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Switching Between Intravenous and Oral P2Y 12 Inhibition: Easier Said Than Done. JACC Cardiovasc Interv 2023; 16:47-49. [PMID: 36599586 DOI: 10.1016/j.jcin.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 01/03/2023]
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Franchi F, Ortega-Paz L, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Reiter B, Jilma B, Angiolillo DJ. Cangrelor in Patients With Coronary Artery Disease Pretreated With Ticagrelor: The Switching Antiplatelet (SWAP)-5 Study. JACC Cardiovasc Interv 2023; 16:36-46. [PMID: 36317958 DOI: 10.1016/j.jcin.2022.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are no studies specifically designed to rule out a drug-drug interaction (DDI) when cangrelor is used among patients who have been pretreated with ticagrelor. OBJECTIVES This study sought to rule out a DDI among cangrelor-treated patients who have been pretreated with ticagrelor. METHODS In this prospective, randomized, double-blind, placebo-controlled, crossover, pharmacokinetic (PK) and pharmacodynamic (PD) study, patients with coronary artery disease (N = 20) were pretreated with a 180-mg ticagrelor loading dose and after 1 hour randomized to placebo or cangrelor (bolus and infusion for 2 hours). Patients crossed over after 1 to 4 weeks of washout. PK analysis included ticagrelor plasma levels and its active metabolite. PD assessments included VerifyNow P2Y12 reaction units (PRU), light transmittance aggregometry, vasodilator-stimulated phosphoprotein, and Total Thrombus-Formation Analysis System. PK/PD assessments were performed at 7 time points. RESULTS Compared with placebo, adding cangrelor to patients pretreated with ticagrelor resulted in a significant reduction in PRU at 30 minutes and 1 hour after starting infusion. At 2 hours after stopping cangrelor/placebo infusion, PRU were low and similar in both groups (16.9 vs 12.6; mean difference: 4.3; 95% CI: -28.6 to 37.3), meeting the noninferiority primary endpoint (predefined noninferiority margin 45 PRU). Consistent findings were shown with all PD assays. PK tracked PD findings with no differences between groups in plasma levels of ticagrelor and its metabolite. CONCLUSIONS Compared with placebo, the use of cangrelor in patients pretreated with ticagrelor results in enhanced platelet inhibition with no differences in PK/PD profiles after discontinuation of drug infusion indicating the absence of a DDI. (PD and PK Profiles of Switching Between Cangrelor and Ticagrelor Following Ticagrelor Pre-treatment [SWAP-5]; NCT04634162).
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Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA; Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA.
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11
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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] [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 Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Paolo Calabrò
- U.O.C. Cardiologia Clinica con UTIC. A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
| | - Fabio Chirillo
- U.O.C. Cardiologia Ospedale San Bassiano, Bassano del Grappa (VI), Italy
| | - Cristina Rolfo
- S.C. Cardiologia Ospedale degli Infermi di Rivoli ASLTO3, Rivoli, Italy
| | - Alberto Menozzi
- S.C. Cardiologia, Ospedale S. Andrea, ASL5 Liguria, La Spezia, Italy
| | | | | | - Elisa Nicolini
- U.O. Cardiologia Interventistica, strutturale e pediatrica, Ospedali Riuniti, Ancona, Italy
| | - Ciro Mauro
- Cardiologia UTIC con emodinamica AORN Cardarelli Napolii, Napoli, Italy
| | - Carlo Trani
- U.O.C. Interventistica Cardiologica e diagnostica invasiva Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Francesco Versaci
- Department of Cardiology, Santa Maria Goretti Hospital, Latina, Italy
| | | | | | - Carlo Di Mario
- Interventistica Cardiologica Strutturale A.O.U. Careggi, Firenze, Italy
| | - Martino Pepe
- Cardiologia Universitaria A.O.U. Consorziale Policlinico, Bari, Italy
| | - Sergio Berti
- Fondazione C.N.R. Reg. Toscana G. Monasterio, Pisa, Italy
| | | | - Plinio Cirillo
- Dipartimento di Scienze Biomediche Avanzate, Cardiologia, A.O.U.P. "Federico II", Napoli, Italy
| | - Diego Maffeo
- Cardiologia Emodinamica Fondazione Poliambulanza, Brescia, Italy
| | - Giuseppe Talanas
- U.O.C. Cardiologia Clinica ed Interventistica, Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy
| | - Marco Ferlini
- U.O.C. Cardiologia Fondazione IRCCS Policlinico San Matteo, San Matteo, Italy
| | - Marco Contarini
- U.O.C. di Cardiologia con UTIC ed Emodinamica Ospedale Umberto I di Siracusa Azienda Sanitaria Provinciale di, Siracusa, Italy
| | | | - Marino Scherillo
- U.O.C. Cardiologia interventistica e UTIC Azienda Ospedaliera San Pio, Benevento, Italy
| | - Giuseppe Tarantini
- U.O.S.D. Emodinamica e Cardiologia Interventistica Azienda Ospedale Università, Padova, Italy
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12
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Kumar K, Golwala H. Antiplatelet Agents in Acute ST Elevation Myocardial Infarction. Am J Med 2022; 135:697-708. [PMID: 35202571 DOI: 10.1016/j.amjmed.2022.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/28/2022]
Abstract
Platelet aggregation and thrombus formation represent the basic mechanism for clinical, electrocardiographic, and biomarker changes consistent with acute coronary syndrome. Various oral and intravenous formulations of platelet function inhibitors have been developed to help decrease platelet aggregation due to acute atherosclerotic plaque rupture. In this article, we review the various mechanisms, pharmacokinetics/pharmacodynamics, and the key clinical trials related to the platelet inhibitors that form the basis for current recommendations of their use in the ST elevation myocardial infarction guidelines by the American College of Cardiology/American Heart Association.
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Affiliation(s)
- Kris Kumar
- Oregon Health and Science University, Portland, Ore
| | - Harsh Golwala
- Oregon Health and Science University, Portland, Ore.
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13
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Scarparo P, van Gameren M, Wilschut J, Daemen J, Den Dekker WK, Zijlstra F, Van Mieghem NM, Diletti R. Impact of thrombus burden on long-term clinical outcomes in patients with either anterior or non-anterior ST-segment elevation myocardial infarction. J Thromb Thrombolysis 2021; 54:47-57. [PMID: 34826103 PMCID: PMC9259523 DOI: 10.1007/s11239-021-02603-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 11/25/2022]
Abstract
Large thrombus burden (LTB) during ST-segment elevation myocardial infarction (STEMI) could translate into worse clinical outcomes. The impact of a LTB in terms of long-term clinical outcomes on different myocardial infarct territories has not yet been fully evaluated. From April 2002 to December 2004, consecutive patients with STEMI undergoing percutaneous coronary intervention with drug eluting stent were evaluated. The study sample was stratified in two groups: anterior STEMI and non-anterior STEMI. LTB was considered as a thrombus larger than or equal to 2-vessel diameters, and small thrombus burden less than 2-vessel diameters. Major adverse cardiac events (MACE) were evaluated at 10-year and survival data were collected up to 15-year. A total of 812 patients were evaluated, 6 patients were excluded due to inadequate angiographic images, 410 (50.9%) had an anterior STEMI and 396 (49.1%) a non-anterior STEMI. Patients with LTB had higher rates of 10-year mortality (aHR 2.27, 95%CI 1.42–3.63; p = 0.001) and 10-year MACE (aHR 1.46, 95%CI 1.03–2.08; p = 0.033) in anterior STEMI, but not in non-anterior STEMI (aHR 0.78, 95%CI 0.49–1.24; p = 0.298; aHR 0.71, 95%CI 0.50–1.02; p = 0.062). LTB was associated with increased 30-day mortality (aHR 5.60, 95%CI 2.49–12.61; p < 0.001) and 30-day MACE (aHR 2.72, 95%CI 1.45–5.08; p = 0.002) in anterior STEMI, but not in non-anterior STEMI (aHR 0.39, 95%CI 0.15–1.06; p = 0.066; aHR 0.67, 95%CI 0.31–1.46; p = 0.316). Beyond 30-day, LTB had no impact on mortality and MACE in both groups. In anterior STEMI, LTB is associated with worse long-term clinical outcomes, this effect was driven by early events.
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Affiliation(s)
- Paola Scarparo
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Jeroen Wilschut
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wijnand K Den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands.
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14
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Gall E, Lafont A, Varenne O, Dumas F, Cariou A, Picard F. Balancing thrombosis and bleeding after out-of-hospital cardiac arrest related to acute coronary syndrome: A literature review. Arch Cardiovasc Dis 2021; 114:667-679. [PMID: 34565694 DOI: 10.1016/j.acvd.2021.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 12/29/2022]
Abstract
Balance between thrombosis and bleeding is now well recognized in patients treated for acute coronary syndrome, with impact on short- and long-term prognosis, including survival. Recent data suggest that patients who are resuscitated after out-of-hospital cardiac arrest related to myocardial infarction are at an even higher risk of bleeding and thrombosis than those with uncomplicated acute coronary syndrome. Delayed enteral absorption of medication due to induced hypothermia and systemic inflammation increases thrombosis risk, whereas transfemoral access site, cardiopulmonary resuscitation manoeuvres and mechanical circulatory support devices increase bleeding risk. In addition, post-resuscitation syndrome and renal or hepatic impairment are potential risk factors for both bleeding and thrombotic complications. There are currently no randomized controlled trials comparing various P2Y12 inhibitor and/or anticoagulation strategies in the setting of out-of-hospital cardiac arrest, and current practice is largely derived from management of patients with uncomplicated acute coronary syndrome. The aim of this review is therefore to describe the bleeding and thrombosis risk factors in this specific population, and to review recent data on antithrombotic drugs in this patient subset.
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Affiliation(s)
- Emmanuel Gall
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alexandre Lafont
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Olivier Varenne
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Florence Dumas
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alain Cariou
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Fabien Picard
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France.
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15
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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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16
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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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17
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Pepe M, Larosa C, Cirillo P, Carulli E, Forleo C, Nestola PL, Ercolano V, D'Alessandro P, Giordano A, Biondi-Zoccai G, Moscarelli M, Palmiotto AI, Esposito G, Favale S. Clinical use of cangrelor: a real world multicenter experience from South Italy Insights from the M.O.Ca. registry. Panminerva Med 2021; 64:9-16. [PMID: 34060281 DOI: 10.23736/s0031-0808.21.04437-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and oral P2Y12 inhibitor (P2Y12-I) represents the standard of care for patients with acute coronary syndromes (ACS) or with chronic coronary syndromes (CCS) treated with percutaneous coronary intervention (PCI). Cangrelor, the first intravenous P2Y12-I, is deemed to overcome the drawbacks of the oral administration; nevertheless real world data on this new drug are scanty. We sought to investigate routine clinical use of cangrelor in four interventional centers of Italy. METHODS We enrolled 241 consecutive patients (196 ACS, 45 CCS) treated with cangrelor during PCI. Drug administration modalities and in-hospital clinical outcomes were evaluated. A subanalysis in patients selected on the basis of the CHAMPION Phoenix trial inclusion/exclusion criteria (CHAMPION-like subpopulation) was also performed. RESULTS Cangrelor was mainly utilized in ACS patients, who presented poorer clinical conditions and higher bleeding risk. Cangrelor was given only in P2Y12-I naïve patients; switch to clopidogrel was always done at the end of the infusion, while ticagrelor or prasugrel were prevalently given 30 minutes before. In-hospital mortality was 10.0% and GUSTO moderate/severe bleeding was 2.5%. Bleeding data showed nevertheless to be in line with the CHAMPION Phoenix results in the "CHAMPION-like" subpopulation. CONCLUSIONS Cangrelor was predominantly used in ACS with modalities substantially in accord with the label indications. Poor clinical outcomes are due to the prevalent utilization in highly challenging clinical settings, nevertheless the rate of bleeding and stent thrombosis are in line with the randomized trials if analyzed in a subpopulation of comparable risk profile.
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Affiliation(s)
- Martino Pepe
- Cardiovascular Diseases Section, Cardiothoracic Department (DAI), University of Bari, Bari, Italy -
| | - Claudio Larosa
- Division of Cardiology, Lorenzo Bonomo Hospital, Andria, Italy
| | - Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, School of Medicine, Federico II University, Naples, Italy
| | - Eugenio Carulli
- Cardiovascular Diseases Section, Cardiothoracic Department (DAI), University of Bari, Bari, Italy
| | - Cinzia Forleo
- Cardiovascular Diseases Section, Cardiothoracic Department (DAI), University of Bari, Bari, Italy
| | - Palma L Nestola
- Cardiovascular Diseases Section, Cardiothoracic Department (DAI), University of Bari, Bari, Italy
| | - Vincenzo Ercolano
- Division of Cardiology, Department of Advanced Biomedical Sciences, School of Medicine, Federico II University, Naples, Italy
| | | | - Arturo Giordano
- Invasive Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital GVM Care & Research, Cotignola, Ravenna, Italy
| | | | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, School of Medicine, Federico II University, Naples, Italy
| | - Stefano Favale
- Cardiovascular Diseases Section, Cardiothoracic Department (DAI), University of Bari, Bari, Italy
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18
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Orban M, Kleeberger J, Ouarrak T, Freund A, Feistritzer HJ, Fuernau G, Geisler T, Huber K, Dudek D, Noc M, Montalescot G, Neumer A, Haller P, Clemmensen P, Zeymer U, Desch S, Massberg S, Schneider S, Thiele H, Hausleiter J. Clopidogrel vs. prasugrel vs. ticagrelor in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis. Clin Res Cardiol 2021; 110:1493-1503. [PMID: 33999281 PMCID: PMC8405498 DOI: 10.1007/s00392-021-01866-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/30/2021] [Indexed: 11/25/2022]
Abstract
Aims The aim of this pooled sub-analysis of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial was to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated either with clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor. Methods and results For the current analysis the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. 856 patients were eligible for analysis. Of these, 507 patients (59.2%) received clopidogrel, 178 patients (20.8%) prasugrel and 171 patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ significantly between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60–1.09, padj = 0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65–1.15, padj = 0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20 -0.69, padj = 0.002) and not significantly different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43 -1.24, padj = 0.24). Conclusion This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that acute therapy with either clopidogrel, prasugrel or ticagrelor is no independent predictor of 1-year mortality. Treatment with ticagrelor seems independently associated with less in-hospital moderate and severe bleeding events compared to clopidogrel. This finding might be due to selection bias and should be interpreted with caution. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01866-3.
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Affiliation(s)
- Martin Orban
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany.
- Medizinische Klinik und Poliklinik I, LMU Klinikum München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Germany.
| | - Jan Kleeberger
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Taoufik Ouarrak
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Anne Freund
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | | | - Kurt Huber
- Medical Faculty, 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, and Sigmund Freud University, Vienna, Austria
| | | | - Marko Noc
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gilles Montalescot
- Sorbonne Université, ACTION Group, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Alexander Neumer
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Paul Haller
- Universitäres Herz- Und Gefäßzentrum UKE Hamburg, Klinik Und Poliklinik Für Kardiologie, Hamburg, Germany
| | - Peter Clemmensen
- Universitäres Herz- Und Gefäßzentrum UKE Hamburg, Klinik Und Poliklinik Für Kardiologie, Hamburg, Germany
| | - Uwe Zeymer
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | | | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
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19
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Guedeney P, Collet JP. Antithrombotic Therapy in Acute Coronary Syndromes: Current Evidence and Ongoing Issues Regarding Early and Late Management. Thromb Haemost 2021; 121:854-866. [PMID: 33506483 DOI: 10.1055/s-0040-1722188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A few decades ago, the understanding of the pathophysiological processes involved in the coronary artery thrombus formation has placed anticoagulant and antiplatelet agents at the core of the management of acute coronary syndrome (ACS). Increasingly potent antithrombotic agents have since been evaluated, in various association, timing, or dosage, in numerous randomized controlled trials to interrupt the initial thrombus formation, prevent ischemic complications, and ultimately improve survival. Primary percutaneous coronary intervention, initial parenteral anticoagulation, and dual antiplatelet therapy with potent P2Y12 inhibitors have become the hallmark of ACS management revolutionizing its prognosis. Despite these many improvements, much more remains to be done to optimize the onset of action of the various antithrombotic therapies, for further treating and preventing thrombotic events without exposing the patients to an unbearable hemorrhagic risk. The availability of various potent P2Y12 inhibitors has opened the door for individualized therapeutic strategies based on the clinical setting as well as the ischemic and bleeding risk of the patients, while the added value of aspirin has been recently challenged. The strategy of dual-pathway inhibition with P2Y12 inhibitors and low-dose non-vitamin K antagonist oral anticoagulant has brought promising results for the early and late management of patients presenting with ACS with and without indication for oral anticoagulation. In this updated review, we aimed at describing the evidence supporting the current gold standard of antithrombotic management of ACS. More importantly, we provide an overview of some of the ongoing issues and promising therapeutic strategies of this ever-evolving topic.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
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20
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Agewall S. Focus on blood pressure and risk factor intervention. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 6:339-340. [PMID: 33197927 DOI: 10.1093/ehjcvp/pvaa130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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21
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Gargiulo G, Esposito G, Avvedimento M, Nagler M, Minuz P, Campo G, Gragnano F, Manavifar N, Piccolo R, Tebaldi M, Cirillo P, Hunziker L, Vranckx P, Leonardi S, Heg D, Windecker S, Valgimigli M. Cangrelor, Tirofiban, and Chewed or Standard Prasugrel Regimens in Patients With ST-Segment-Elevation Myocardial Infarction: Primary Results of the FABOLUS-FASTER Trial. Circulation 2020; 142:441-454. [PMID: 32795098 PMCID: PMC7392586 DOI: 10.1161/circulationaha.120.046928] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Standard administration of newer oral P2Y12 inhibitors, including prasugrel or ticagrelor, provides suboptimal early inhibition of platelet aggregation (IPA) in patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention. We aimed to investigate the effects of cangrelor, tirofiban, and prasugrel, administered as chewed or integral loading dose, on IPA in patients undergoing primary percutaneous coronary intervention. Methods: The FABOLUS-FASTER trial (Facilitation Through Aggrastat or Cangrelor Bolus and Infusion Over Prasugrel: A Multicenter Randomized Open-Label Trial in Patients with ST-Elevation Myocardial Infarction Referred for Primary Percutaneous Intervention) is an investigator-initiated, multicenter, open-label, randomized study. A total of 122 P2Y12-naive patients with ST-segment–elevation myocardial infarction were randomly allocated (1:1:1) to cangrelor (n=40), tirofiban (n=40) (both administered as bolus and 2-hour infusion followed by 60 mg of prasugrel), or 60-mg loading dose of prasugrel (n=42). The latter group underwent an immediate 1:1 subrandomization to chewed (n=21) or integral (n=21) tablets administration. The trial was powered to test 3 hypotheses (noninferiority of cangrelor compared with tirofiban using a noninferiority margin of 9%, superiority of both tirofiban and cangrelor compared with chewed prasugrel, and superiority of chewed prasugrel as compared with integral prasugrel, each with α=0.016 for the primary end point, which was 30-minute IPA at light transmittance aggregometry in response to 20 μmol/L adenosine diphosphate. Results: At 30 minutes, cangrelor did not satisfy noninferiority compared with tirofiban, which yielded superior IPA over cangrelor (95.0±8.9 versus 34.1±22.5; P<0.001). Cangrelor or tirofiban were both superior to chewed prasugrel (IPA, 10.5±11.0; P<0.001 for both comparisons), which did not provide higher IPA over integral prasugrel (6.3±11.4; P=0.47), despite yielding higher prasugrel active metabolite concentration (ng/mL; 62.3±82.6 versus 17.1±43.5; P=0.016). Conclusions: Cangrelor provided inferior IPA compared with tirofiban; both treatments yielded greater IPA compared with chewed prasugrel, which led to higher active metabolite concentration but not greater IPA compared with integral prasugrel. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02978040; URL: https://www.clinicaltrialsregister.eu; EudraCT 2017-001065-24.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital (M.N.), University of Bern, Switzerland
| | - Pietro Minuz
- Department of Medicine, Unit of General Medicine for the Study and Treatment of Hypertensive Disease, University of Verona, Policlinico GB Rossi, Italy (P.M.)
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Italy (G.C., M.T.)
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy (G.C.)
| | - Felice Gragnano
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli,” Naples, Italy (F.G.)
| | - Negar Manavifar
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Matteo Tebaldi
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Italy (G.C., M.T.)
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Lukas Hunziker
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Belgium (P.V.)
| | - Sergio Leonardi
- University of Pavia and Fondazione IRCCS Policlinico S Matteo, Italy (S.L.)
| | - Dik Heg
- Bern University Hospital, and Clinical Trials Unit, CTU Bern (D.H.), University of Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
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22
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Agewall S. Antiplatelet treatment in coronary syndrome. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:81-82. [PMID: 33720341 DOI: 10.1093/ehjcvp/pvab015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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23
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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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24
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Gorog DA, Price S, Sibbing D, Baumbach A, Capodanno D, Gigante B, Halvorsen S, Huber K, Lettino M, Leonardi S, Morais J, Rubboli A, Siller-Matula JM, Storey RF, Vranckx P, Rocca B. Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a joint position paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:125-140. [PMID: 32049278 DOI: 10.1093/ehjcvp/pvaa009] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/10/2020] [Accepted: 02/04/2020] [Indexed: 12/19/2022]
Abstract
Timely and effective antithrombotic therapy is critical to improving outcome, including survival, in patients with acute coronary syndrome (ACS). Achieving effective platelet inhibition and anticoagulation, with minimal risk, is particularly important in high-risk ACS patients, especially those with cardiogenic shock (CS) or those successfully resuscitated following out-of-hospital cardiac arrest (OHCA), who have a 30-50% risk of death or a recurrent ischaemic event over the subsequent 30 days. There are unique challenges to achieving effective and safe antithrombotic treatment in this cohort of patients that are not encountered in most other ACS patients. This position paper focuses on patients presenting with CS or immediately post-OHCA, of presumed ischaemic aetiology, and examines issues related to thrombosis and bleeding risk. Both the physical and pharmacological impacts of CS, namely impaired drug absorption, metabolism, altered distribution and/or excretion, associated multiorgan failure, co-morbidities and co-administered treatments such as opiates, targeted temperature management, renal replacement therapy and circulatory or left ventricular assist devices, can have major impact on the effectiveness and safety of antithrombotic drugs. Careful attention to the choice of antithrombotic agent(s), route of administration, drug-drug interactions, therapeutic drug monitoring and factors that affect drug efficacy and safety, may reduce the risk of sub- or supra-therapeutic dosing and associated adverse events. This paper provides expert opinion, based on best available evidence, and consensus statements on optimising antithrombotic therapy in these very high-risk patients, in whom minimising the risk of thrombosis and bleeding is critical to improving outcome.
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Affiliation(s)
- Diana A Gorog
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
| | - Susanna Price
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Dirk Sibbing
- Ludwig-Maximilians-Universität, München, Medizinische Klinik und Poliklinik I, Campus Großhadern, München, Germany
| | - Andreas Baumbach
- Barts Heart Centre, William Harvey Research Institute, Bartshealth NHS Trust, Queen Mary University of London, West Smithfield, London, UK
| | - Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Bruna Gigante
- Unit of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science, Danderyds Hospital, Danderyd, Sweden
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria.,Sigmund Freud University, Medical School, Vienna, Austria
| | - Maddalena Lettino
- Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Sergio Leonardi
- Coronary Care Unit, University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Joao Morais
- Cardiology Division, Leiria Hospital Center, Pousos, Leiria, Portugal.,ciTechCare, Polytechnic of Leiria, Leiria, Portugal
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases - AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy
| | | | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
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25
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Alexopoulos D, Varlamos C, Mpahara A, Lianos I. P2Y12 inhibitors for the treatment of acute coronary syndrome patients undergoing percutaneous coronary intervention: current understanding and outcomes. Expert Rev Cardiovasc Ther 2019; 17:717-727. [PMID: 31583920 DOI: 10.1080/14779072.2019.1675513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Inhibition of P2Y12 platelet receptors consists a crucial target of pharmacologic treatment in acute coronary syndrome patients. Several controversial issues however still remain and these are analyzed.Areas covered: The significance of early and strong platelet inhibition in the early phase of STEMI and the role of pretreatment are discussed. Concerns regarding morphine administration are raised. The role of crushing integral tablets to expedite the onset of action of oral P2Y12 inhibitors is emphasized. New data on the intravenous cangrelor are reported. Antiplatelet therapies as adjunct to thrombolysis, as well as the role of de-escalation antiplatelet therapy are analyzed.Expert opinion: Pharmacodynamic studies convincingly demonstrate a gap in the onset of antiplatelet action in STEMI cases, even when prasugrel or ticagrelor loading dose is used. The clinical benefit, however, of the early platelet inhibition and pretreatment is not entirely clear. Morphine delays the onset of action of oral agents, while this is expedited by crushing the integral tablets. Cangrelor devoids of these deficiencies by achieving fast and strong platelet inhibition in all clinical scenarios. Concomitant administration of novel antiplatelet agents with thrombolysis and de-escalation of antiplatelet treatment necessitate further study to reach definite conclusion.
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Affiliation(s)
- Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalampos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Aikaterini Mpahara
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Lianos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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