Bridging Experience With Eptifibatide After Stent Implantation

Efficacy and safety of a bridging strategy that uses intravenous platelet glycoprotein receptor inhibitors for patients undergoing surgery after coronary stent implantation: a meta-analysis

BACKGROUND

Current guidelines indicate we can consider a bridging strategy that uses intravenous, reversible glycoprotein inhibitors for patients that required surgery following recent stent implantation. However, no strong clinical evidence exists that demonstrates the efficacy and safety of this treatment. Therefore, in this study, the efficacy and safety of a bridging strategy that uses intravenous platelet glycoprotein receptor inhibitors will be evaluated.

METHODS

A meta-analysis was performed on preoperative bridging studies in patients undergoing coronary stent surgery. The primary outcome was the success rate of no major adverse cardiovascular events (MACE). The secondary outcomes were the success rate of no reoperations to stop bleeding.

RESULTS

A total of 10 studies that included 382 patients were used in this meta-analysis. For the primary endpoint, the success rate was 97.7% (95% CI 94.4-98.0%) for glycoprotein IIb/IIIa inhibitors, 98.8% (95% CI 96.0-100%) for tirofiban (6 studies) and 95.8% (95% CI 90.4-99.4%) for eptifibatide (4 studies). For secondary endpoints, the success rate was 98.0% (95% CI 94.8-99.9%) for glycoprotein IIb/IIIa inhibitors, 99.7% (95% CI 97.1-100%) for tirofiban (5 studies), and 95.3% (95% CI 88.5-99.4%) for eptifibatide (4 studies).

CONCLUSION

The results of this study showed that the use of intravenous platelet glycoprotein IIb/IIIa inhibitors as a bridging strategy might be safe and effective for patients undergoing coronary stent implantation that require surgery soon after.

Cangrelor in STEMI as a bridge to CABG- a mini-case series

Background

Patients with STEMI receive dual antiplatelet therapy as soon as possible with aspirin and a P2Y12 receptor antagonist prior to PCI. A fraction of these patients may have multi-vessel disease needing emergent CABG surgery. The choice of a P2Y12 receptor antagonist plays a role in the timing of CABG surgery as it poses a bleeding risk until it is completely eliminated from the system. Oral P2Y12 receptor antagonists have a long duration of platelet inhibition which is difficult to reverse. Cangrelor is an intravenous P2Y12 receptor antagonist with a short half-life and rapid cessation of its effect after discontinuation.

Methods

Three patients who presented to our emergency department with STEMI were started on cangrelor infusion prior to cardiac catheterization instead of other P2Y12 receptor antagonists like clopidogrel or ticagrelor. The study received ethical approval as it is part of the current standard of care for STEMI patients.

Results

All three patients were found to have multi-vessel disease during coronary angiography requiring CABG surgery. As cangrelor was used in these patients they were able to have their surgery within 24-48 h. Intravenous cangrelor was stopped about an hour before surgery. No bleeding complications occurred and all three patients made a speedy recovery in the ICU.

Conclusion

Cangrelor is a potent P2Y12 receptor antagonist which can be used in patients presenting with STEMI as one of the two anti-platelet agents along with aspirin without any dilemma that it would cause a delay in CABG surgery if the patients need one.

Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention: JACC Review Topic of the Week

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.

Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety

OBJECTIVE

To review the efficacy and safety of perioperative administration of intravenous (IV) antiplatelet agents as a substitute for oral P2Y₁₂ inhibitors and to provide clinicians guidance on optimal and cost-effective use of these medications.

DATA SOURCES

A MEDLINE literature search (1950 to November 2018) was performed using the key search terms abciximab, bridging, cangrelor, cardiac surgery, coronary artery bypass surgery, eptifibatide, intravenous antiplatelet agent, and tirofiban. Additional references were identified from a review of literature citations.

STUDY SELECTION AND DATA EXTRACTION

In all, 18 original research reports and case reports/series were included in the review.

DATA SYNTHESIS

Prevention of postoperative bleeding is critical to decrease morbidity and mortality after cardiac surgery. IV antiplatelet medications have short half-lives and are frequently used to substitute for oral P2Y₁₂ inhibitors to allow platelet function recovery before procedures. Functional recovery of platelets is delayed after abciximab discontinuation and increases postoperative bleeding risk. Eptifibatide and tirofiban have similar pharmacokinetic/pharmacodynamic properties and comparable efficacy and safety in the setting of perioperative bridging. Cangrelor may be considered in patients with renal insufficiency as decreased clearance of eptifibatide or tirofiban may increase the risk of postoperative bleeding. Relevance to Patient Care and Clinical Practice: Comparative studies of IV antiplatelet medications have not been published. Appropriate use of IV antiplatelet medications can prevent perioperative ischemic events and bleeding.

CONCLUSIONS

Eptifibatide, tirofiban, and cangrelor are preferred over abciximab as a perioperative bridge. The choice of agent should be tailored to clinical characteristics of the patient and institutional acquisition costs.

Antiplatelet Therapy Bridging With Cangrelor in Patients With Coronary Stents: A Case Series

BACKGROUND

Cangrelor is an intravenous P2Y₁₂ receptor antagonist approved for use during percutaneous coronary intervention (PCI) to reduce ischemic events associated with new stent placement and has been used off-label at reduced doses guided by platelet function testing as a "bridge" from discontinuation of oral P2Y₁₂ receptor antagonists to surgical procedures when the long-term effects of oral agents are undesirable.

OBJECTIVE

To describe the dosing, laboratory monitoring, and clinical outcomes of a series of patients who received cangrelor as a "bridging" antiplatelet agent.

METHODS

This study is a retrospective analysis of all patients within the study center with coronary stents who received cangrelor as a bridge to surgical procedure and had VerifyNow monitoring during treatment.

RESULTS

A total of 11 patients were identified for inclusion. The median cangrelor dose was 0.5 µg/kg/min (interquartile range = 0.5-0.5) and was maintained in 7 of 11 patients. Doses ranged from 0.25 to 2 µg/kg/min during therapy, and 81.6% of VerifyNow results assessed were within goal range (⩽208 P2Y₁₂ reaction units). Bleeding complications during therapy occurred in 3 patients, all of whom were receiving concomitant heparin infusions, and no stent thrombosis was reported. Conclusion and Relevance: Low-dose cangrelor may represent an effective option for bridging antiplatelet therapy in patients with coronary stents. This study demonstrated that the majority of patients received adequate platelet inhibition without any incidence of stent thrombosis on 0.5 µg/kg/min using the VerifyNow assay to monitor platelet inhibition, which represents a lower dose than previously reported in the literature.

Cangrelor for the treatment of patients with Arterial Thrombosis

INTRODUCTION

All oral P2Y₁₂ receptor blockers are associated with some degree of delayed onset and offset of pharmacodynamic (PD) effects in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI). Although intravenous glycoprotein IIb/IIIa inhibitors are associated with rapid onset of action, they are also associated with delayed offset and other limitations such as elevated bleeding risk and thrombocytopenia. Areas covered: In this review, the authors focus on cangrelor, an intravenous, reversible P2Y₁₂ receptor blocker with fast onset and offset of effects. The authors also describe the pharmacologic effects of cangrelor and its pharmacologic interaction with other P2Y₁₂ receptor inhibitors. Finally, the authors discuss the large-scale clinical trials that compared the efficacy and safety of cangrelor with clopidogrel. Expert opinion: In ACS patients undergoing PCI, cangrelor is most desirable to effectively prevent periprocedural ischemic events and to avoid excessive bleeding. Indeed, any high-risk patient with ST-segment elevation myocardial infraction or patient who is unable to take oral medications is a potential candidate for intravenous cangrelor therapy. Furthermore, stable patients with coronary artery disease, who are considered for ad hoc PCI following coronary angiography, may be considered for treatment with cangrelor to reduce post-PCI thrombotic events.

Cangrelor: A New Route for P2Y12 Inhibition

Antiplatelet therapy with a P2Y12 inhibitor is a key component of treatment for patients with acute coronary syndromes undergoing percutaneous coronary intervention. Before the development of cangrelor (Kengreal, The Medicines Company, Parsippany, NJ), only oral P2Y12 inhibitors were available. Cangrelor is a reversible P2Y12 inhibitor that is administered as an intravenous infusion, and its quick onset and offset make it an appealing option for antiplatelet therapy, particularly for patients who are unable to take oral medications. Although cangrelor struggled to show benefit in early trials, the positive results of the CHAMPION PHOENIX trial led to its approval for use as an adjunct to percutaneous coronary intervention to reduce the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients who have not been treated with another P2Y12 inhibitor and are not being given a glycoprotein IIb/IIIa inhibitor. Cangrelor has also been evaluated as an option for bridging therapy in patients who must discontinue their oral P2Y12 inhibitor before coronary artery bypass grafting. This review of cangrelor will discuss its mechanism of action, its pharmacodynamics and pharmacokinetics, the clinical trial experience, and its potential place in therapy.

Perioperative Management of Dual-Antiplatelet Therapy in Patients With New-Generation Drug-Eluting Metallic Stents and Bioresorbable Vascular Scaffolds Undergoing Elective Noncardiac Surgery

Dual-antiplatelet therapy (DAPT) is considered mandatory after new-generation drug-eluting coronary stent implantation to reduce ischemic complications such as stent thrombosis, but the need for DAPT makes the timing of elective surgery difficult. Interrupting DAPT places patients at risk for stent thrombosis, and surgery in the setting of DAPT may lead to bleeding. The 2016 American College of Cardiology/American Heart Association guideline recommends delaying elective noncardiac surgery for a minimum 6-month period to reduce ischemic risks after the implantation of a second-generation metallic drug-eluting stent (DES). However, the guideline fails to appropriately stratify surgical patients based on the indication for second-generation metallic DES implantation and other patient characteristics. The Absorb bioresorbable vascular scaffold (Abbott Vascular, Abbott Park, IL), which has a higher propensity for stent thrombosis compared with second-generation metallic DES, also produces DAPT management challenges in patients presenting for elective noncardiac surgery. Due to the novelty of bioresorbable vascular scaffold therapy, there are no guidelines available for the management of patients undergoing elective noncardiac surgery. This review addresses DAPT management in patients undergoing noncardiac surgery less than 12 months after new-generation metallic DES or bioresorbable vascular scaffold implantation and provides further guidance for anesthesiologists who encounter these challenging cases.