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Chakraborty S, Sarkar D, Samajdar SS, Biswas P, Mohapatra D, Halder S, Yunus M. Efficacy and safety of cangrelor as compared to ticagrelor in patients with ST-elevated myocardial infarction (STEMI): a systematic review and meta-analysis. Egypt Heart J 2024; 76:48. [PMID: 38625596 PMCID: PMC11021388 DOI: 10.1186/s43044-024-00480-8] [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: 12/30/2023] [Accepted: 04/08/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND This systematic review and meta-analysis aimed to compare the efficacy and safety of cangrelor as compared to ticagrelor in patients with ST-elevated myocardial infarction (STEMI) who underwent percutaneous intervention. METHODS PubMed, Embase, Scopus, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov databases were searched for relevant head-on-comparison or swapping studies. The primary outcome was the rate of high platelet reactivity (HPR) at specific time intervals after stopping cangrelor infusion during the first 24 h. Secondary outcomes were the risks of thrombosis, all-cause mortality and bleeding. Pooled odds ratios (ORs) were calculated using random-effects models. RESULTS A total of 1018 studies were screened and eight were included in the analysis. There were four head-on-comparison studies and four swapping studies. There was no significant difference in the proportion of patients achieving a high platelet reactivity in swapping studies [OR, 0.71 (95% CI 0.04, 13.87), p = 0.82, i2 = 88%]. In head-on-comparison studies, PRU from Fig. 2B shows there was no significant reduction in high platelet reactivity [mean difference - 77.83 (95% CI - 238.84, 83.18), p < 0.001, i2 = 100%]. PRU results from (Fig. 2C) show a mean difference of 7.38 (95% CI - 29.74, 44.51), p < 0.001, i2 = 97%. There was no significant difference in the risks of thrombosis [OR, 0.91 (95% CI 0.20, 4.13), p = 0.81, i2 = 0%], all-cause mortality [OR, 3.52 (95% CI 0.44, 27.91), p = 0.24, i2 = 26%] and bleeding [OR, 0.89 (95% CI 0.37, 2.17), p = 0.93, i2 = 0%] between the two groups as revealed in the head-on-comparison studies. CONCLUSION The efficacy and safety profiles of cangrelor and ticagrelor were similar in patients with STEMI.
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Affiliation(s)
- Subhro Chakraborty
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India.
| | - Debalina Sarkar
- Department of Endocrinology, RGKar Medical College, Kolkata, India
| | - Shambo Samrat Samajdar
- School of Tropical Medicine Kolkata, Diabetes and Allergy-Asthma Therapeutics Speciality Clinic, Kolkata, India
| | - Pallab Biswas
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India
| | - Debasish Mohapatra
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India
| | - Saptarshi Halder
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India
| | - Mohammad Yunus
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India
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Kordis P, Berden J, Mikuz U, Noc M. Immediate Platelet Inhibition Strategy for Comatose Out-of-Hospital Cardiac Arrest Survivors Undergoing Percutaneous Coronary Intervention and Mild Therapeutic Hypothermia. J Clin Med 2024; 13:2121. [PMID: 38610886 PMCID: PMC11012382 DOI: 10.3390/jcm13072121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Comatose survivors of out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI) and target temperature management (TTM) are at increased risk of stent thrombosis (ST), partly due to delayed platelet inhibition even with more potent P2Y12 agents. We hypothesized that periprocedural cangrelor would induce immediate platelet inhibition, bridging the "P2Y12 inhibition gap". Methods: In our pilot study, we randomized 30 comatose OHCA patients undergoing PCI and TTM (32-34 °C) into cangrelor and control groups. Both groups received unfractioned heparin, acetylsalicylic acid, and ticagrelor via enteral tube. The cangrelor group also received an intravenous bolus of cangrelor followed by a 4 h infusion. Platelet inhibition was measured using VerifyNow® and Multiplate® ADP at baseline and 1, 3, 5, and 8 h post PCI. Results: Patient characteristics did not differ between groups. VerifyNow® showed significantly decreased platelet reactivity with cangrelor at 1 h (30 vs. 221 PRU; p < 0.001) and 3 h (24 vs. 180 PRU; p < 0.001), with differences at 5 and 8 h. Similarly, the proportion of patients with high on-treatment platelet reactivity (HPR) in the cangrelor group was significantly lower at 1 h (0% vs. 67%; p < 0.001) and 3 h (0% vs. 47%; p = 0.007). Multiplate® ADP was also decreased at 1 h (14 vs. 48 U; p < 0.001) and 3 h (11 vs. 42 U; p = 0.001), with no difference at 5 and 8 h. The occurrence of bleeding events was similar in both groups. Conclusions: Cangrelor safely induced immediate and profound platelet inhibition. We observed no significant drug-drug interaction with ticagrelor.
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Affiliation(s)
- Peter Kordis
- Center for Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (P.K.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Jernej Berden
- Center for Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (P.K.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Ursa Mikuz
- Center for Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (P.K.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (P.K.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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Schilling U, Dingemanse J, Dobrow M, Baumann M, Riederer MA, Juif PE, Ufer M. Insights from In Vitro and Clinical Data to Guide Transition from the Novel P2Y12 Antagonist Selatogrel to Clopidogrel, Prasugrel, and Ticagrelor. Thromb Haemost 2021; 121:755-766. [PMID: 33412611 DOI: 10.1055/s-0040-1721773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Reduced pharmacodynamic (PD) effects of irreversible oral P2Y12 receptor antagonists have been reported when administered during cangrelor infusion. Therefore, the PD interaction liability of the novel P2Y12 receptor antagonist selatogrel with irreversible (i.e., clopidogrel, prasugrel) and reversible (i.e., ticagrelor) oral P2Y12 receptor antagonists was investigated in vitro and in healthy subjects. In vitro, selatogrel reduced the effects of clopidogrel and prasugrel in a concentration-dependent manner, while additive effects were observed for the combination of selatogrel and ticagrelor. Accordingly, a single-center, randomized, double-blind, two-way crossover study was conducted consisting of six groups. In each group (N = 12), an open-label loading dose of 300 or 600 mg clopidogrel, 60 mg prasugrel, or 180 mg ticagrelor was administered 30 minutes (i.e., at t max of selatogrel) or 12 hours after a single subcutaneous dose of 16 mg selatogrel or placebo. Inhibition of platelet aggregation (IPA) was assessed at various time points up to 48 hours. Reduced IPA was determined when clopidogrel or prasugrel was administered 30 minutes after selatogrel (∼40 and 70% lower IPA, respectively, at 24 hours postdosing). However, when administering prasugrel 12 hours after selatogrel, IPA was not impacted (>90% IPA) and in the case of clopidogrel reduced effects were partially mitigated. Similar IPA was determined for ticagrelor when administered 30 minutes after selatogrel or placebo. In conclusion, reduced IPA was observed for clopidogrel and prasugrel when administered after selatogrel, which can be mitigated by applying an appropriate time interval. No PD interaction with ticagrelor was observed.
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Affiliation(s)
- Uta Schilling
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | - Martine Baumann
- Department of Drug Discovery Biology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Markus A Riederer
- Department of Drug Discovery Biology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Pierre-Eric Juif
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
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4
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Elhorany M, Lenck S, Degos V, Sourour NA, Frasca Polara G, Shotar E, Godier A, Drir M, Mahtout J, Premat K, Alamowitch S, Samson Y, Clarençon F. Cangrelor and Stenting in Acute Ischemic Stroke : Monocentric Case Series. Clin Neuroradiol 2020; 31:439-448. [PMID: 32382875 DOI: 10.1007/s00062-020-00907-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Cangrelor is an intravenous P2Y12 receptor inhibitor with a rapid onset/offset of action and a short half-life (3-6 min). The objective was to present a preliminary experience regarding the safety and effectiveness using cangrelor, in combination with aspirin, in acute ischemic stroke patients requiring acute stenting. MATERIAL AND METHODS Retrospective analysis for patients who underwent stenting (intracranial and/or extracranial) in the setting of acute ischemic stroke with cangrelor and aspirin as antiplatelet therapy. RESULTS Cangrelor was used in 12 patients, 4 (33%) with extracranial stenting, 6 (50%) with intracranial stenting and 2 (17%) with combined extracranial and intracranial stenting. The mean age was 67 years (44-88) and 9 patients (75%) were female. The median National Institutes of Health Stroke Score at admission was 15 (IQR: 8-22). Of the patients, six (50%) received intravenous thrombolysis. All patients (100%) obtained modified thrombolysis in cerebral infarction score ≥2b. Good clinical outcome, defined as modified Rankin scale score ≤2 at 3‑months follow-up, was observed in 7 patients (58%). None of the patients experienced intraprocedural thromboembolic complications. Postprocedural stent thrombosis after cessation of cangrelor infusion due to emergency craniotomy surgery to manage malignant cerebral infarction occurred in one patient (8%). Of the patients, two (17%) experienced asymptomatic intracranial hemorrhage (ICH), one patient (8%) experienced symptomatic ICH and one (8%) retroperitoneal hematoma was observed, which was managed conservatively. CONCLUSION Cangrelor might be a safe and effective antiplatelet medication owing to its on/off activity for acute stenting in the setting of acute ischemic stroke. Further investigations through randomized studies with larger samples are necessary.
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Affiliation(s)
- Mahmoud Elhorany
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne University, Paris VI University, Paris, France.,GRC Biofast, Paris VI University, Paris, France.,Department of Neurology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Stephanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Vincent Degos
- Sorbonne University, Paris VI University, Paris, France.,GRC Biofast, Paris VI University, Paris, France.,Department of Neuro Intensive Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Nader-Antoine Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Giulia Frasca Polara
- Sorbonne University, Paris VI University, Paris, France.,Department of Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Anne Godier
- Department of Anesthesiology and Intensive Care, Hôpital Européen Georges Pompidou, INSERM UMRS-1140, Paris Descartes University, Paris, France
| | - Mehdi Drir
- Department of Neuro Intensive Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Jugurtha Mahtout
- Department of Neuro Intensive Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne University, Paris VI University, Paris, France
| | - Sonia Alamowitch
- Sorbonne University, Paris VI University, Paris, France.,Department of Vascular Neurology, Saint-Antoine University Hospital, Paris, France
| | - Yves Samson
- Sorbonne University, Paris VI University, Paris, France.,Department of Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. .,Sorbonne University, Paris VI University, Paris, France. .,GRC Biofast, Paris VI University, Paris, France.
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5
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Buchtele N, Herkner H, Schörgenhofer C, Merrelaar A, Laggner R, Gelbenegger G, Spiel AO, Domanovits H, Lang I, Jilma B, Schwameis M. High Platelet Reactivity after Transition from Cangrelor to Ticagrelor in Hypothermic Cardiac Arrest Survivors with ST-Segment Elevation Myocardial Infarction. J Clin Med 2020; 9:jcm9020583. [PMID: 32098088 PMCID: PMC7073541 DOI: 10.3390/jcm9020583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 12/20/2022] Open
Abstract
Transition from cangrelor to oral P2Y12 inhibitors after PCI carries the risk of platelet function recovery and acute stent thrombosis. Whether the recommended transition regimen is appropriate for hypothermic cardiac arrest survivors is unknown. We assessed the rate of high platelet reactivity (HPR) after transition from cangrelor to ticagrelor in hypothermic cardiac arrest survivors. Adult survivors of out-of-hospital cardiac arrest with ST-segment elevation myocardial infarction (STEMI), who were treated for hypothermia (33 °C ± 1) and received intravenous cangrelor during PCI and subsequent oral loading with 180mg ticagrelor were enrolled in this prospective observational cohort study. Platelet function was assessed using whole blood aggregometry. HPR was defined as AUC > 46U. The primary endpoint was the rate of HPR (%) at predefined time points during the first 24 h after cangrelor cessation. Poisson regression was used to estimate the relationship between the overlap time of cangrelor and ticagrelor co-administration and the number of subsequent HPR episodes, expressed as incidence rate ratio (IRR) with 95% confidence interval (95%CI). Between December 2017 and October 2019 16 patients (81% male, 58 years) were enrolled. On average, ticagrelor was administered 39 min (IQR 5-50) before the end of cangrelor infusion. The rate of HPR was highest 90 min after cangrelor cessation and was present in 44% (7/16) of patients. The number of HPR episodes increased significantly with decreasing overlap time of cangrelor and ticagrelor co-administration (IRR 1.03, 95%CI 1.01-1.05; p = 0.005). In this selected cohort of hypothermic cardiac arrest survivors who received cangrelor during PCI, ticagrelor loading within the recommended time frame before cangrelor cessation resulted in a substantial amount of patients with HPR.
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Affiliation(s)
- Nina Buchtele
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria; (N.B.); (C.S.); (G.G.); (B.J.)
- Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
| | - Christian Schörgenhofer
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria; (N.B.); (C.S.); (G.G.); (B.J.)
| | - Anne Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
| | - Roberta Laggner
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria; (N.B.); (C.S.); (G.G.); (B.J.)
| | - Alexander O. Spiel
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
- Correspondence: ; Tel.: +43-1-40-400-39560
| | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
| | - Irene Lang
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria; (N.B.); (C.S.); (G.G.); (B.J.)
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
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Cohen MV, Downey JM. What Are Optimal P2Y12 Inhibitor and Schedule of Administration in Patients With Acute Coronary Syndrome? J Cardiovasc Pharmacol Ther 2019; 25:121-130. [DOI: 10.1177/1074248419882923] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Guidelines recommend treatment with a P2Y12 platelet adenosine diphosphate receptor inhibitor in patients undergoing elective or urgent percutaneous coronary intervention (PCI), but the optimal agent or timing of administration is still not clearly specified. The P2Y12 inhibitor was initially used for its platelet anti-aggregatory action to block thrombosis of the recanalized coronary artery or deployed stent. It is now recognized that these agents also offer potent cardioprotection against a reperfusion injury that occurs in the first minutes of reperfusion if platelet aggregation is blocked at the time of reperfusion. But this is difficult to achieve with oral agents which are slowly absorbed and often require time-consuming metabolic activation. Patients with ST-segment elevation myocardial infarction who usually have a large mass of myocardium at risk of infarction seldom have sufficient time for upstream-administered oral agents to achieve a therapeutic P2Y12 level of inhibition by the time of balloon inflation. However, optimal treatment could be assured by initiating an IV cangrelor infusion shortly prior to stenting followed by subsequent post-PCI transition to an oral agent, that is, ticagrelor, once success of the recanalization and absence of need for surgical intervention are confirmed. Not only should this sequence provide optimal protection against infarction, it should also negate bleeding if coronary artery bypass grafting should be required since stopping the cangrelor infusion at any time will quickly restore platelet reactivity. It is anticipated that cangrelor-induced myocardial salvage will help preserve myocardial function and significantly diminish postinfarction heart failure.
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Affiliation(s)
- Michael V. Cohen
- Department of Physiology and Cell Biology, University of South Alabama College of Medicine, Mobile, AL, USA
- Department of Medicine, University of South Alabama College of Medicine, Mobile, AL, USA
| | - James M. Downey
- Department of Physiology and Cell Biology, University of South Alabama College of Medicine, Mobile, AL, USA
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7
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Effects of Cangrelor as Adjunct Therapy to Percutaneous Coronary Intervention. Am J Cardiol 2019; 123:1228-1238. [PMID: 30738570 DOI: 10.1016/j.amjcard.2019.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 11/21/2022]
Abstract
Percutaneous coronary intervention (PCI) in patients with angiographic evidence of intracoronary thrombus is associated with in-hospital and 30-day adverse clinical outcomes. Cangrelor, a direct, rapid-onset acting intravenous P2Y12 receptor inhibitor, has been proved to be effective by reducing peri-PCI ischemic complications in subjects who underwent PCI. This study aimed to assess the angiographic and in-hospital clinical outcomes in all-comer patients receiving cangrelor immediately before PCI at a tertiary care center. The study analyzed consecutive unselected subjects treated with cangrelor at the time the decision was made to proceed with PCI. At the end of the procedure, all patients were transitioned to oral antiplatelet therapy. The target lesion angiographic assessment of Thrombolysis in myocardial infarction flow grade (TIMI-Flow), TIMI-thrombus grade (TIMI-Thrombus), myocardial blush grade, and TIMI-myocardial perfusion grade (TMPG) was performed before and post-PCI. Clinical events were recorded during the procedure and at discharge. In total, 223 patients (244 lesions) were included in the analysis (106, 97, and 20 patientswith TIMI-Flow 0/1, TIMI-Flow 2/3, and cardiogenic shock, respectively). The overall mean age was 63 ± 12 years, 70% men and 38% with diabetes mellitus. Acute myocardial infarction was the main presentation (72%). The use of cangrelor improved TIMI-Flow, MGB, TMPG, and TIMI-Thrombus in patients with initial TIMI-Flow 0 to 2. Major bleeding rate was 2.0%. In conclusion, cangrelor was effective and safe in restoring TIMI-Flow 3, reducing thrombus burden and improving myocardial blush grade and TMPG when administered to unselected subjects who underwent PCI. Therefore, cangrelor should be considered in patients presenting with intracoronary thrombus before intervention.
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Meta-Analysis of the Role of Cangrelor for Patients Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2019; 123:1069-1075. [PMID: 30654930 DOI: 10.1016/j.amjcard.2018.12.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 02/01/2023]
Abstract
Inhibition of the P2Y12 receptor by an oral P2Y12 inhibitor with loading doses along with Cyclooxygenase-1 inhibition by aspirin is considered a first-line treatment strategy in patients with the acute coronary syndrome and patients undergoing percutaneous coronary intervention (PCI). Limitations associated with oral P2Y12 receptor inhibitors include a requirement for in vivo conversion (thienopyridines), delayed onset of action, suboptimal inhibition, irreversible inhibition (thienopyridines), and delayed offset. In the acute setting, therapy with potent platelet inhibitors that have a fast onset and offset is desirable to attenuate thrombotic complications. Cangrelor, an intravenous agent, is an adenosine triphosphate analog, selectively and explicitly blocking P2Y12 receptor-mediated platelet activation. Cangrelor has been studied in a series of CHAMPION trials. A patient-level, meta-analysis of all 3 phase III trials (24,910 patients), demonstrated that cangrelor significantly reduced the rate of the composite outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours and 30 days compared with clopidogrel, with no significant increase in major bleeding. It is approved for clinical use in patients undergoing PCI to reduce the risk of myocardial infarction, repeat revascularization, and stent thrombosis in patients who have not been treated with a P2Y12 platelet inhibitor and are not being given a GPIIbIIIa inhibitor. In conclusion, patients unable to take oral medications undergoing emergent/urgent PCI and those who had recent PCI with drug eluting stent in need for urgent cardiac or noncardiac surgery are potential candidates for cangrelor.
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9
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Aguilar-Salinas P, Agnoletto GJ, Brasiliense LBC, Santos R, Granja MF, Gonsales D, Aghaebrahim A, Sauvageau E, Hanel RA. Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study. J Neurointerv Surg 2018; 11:347-351. [PMID: 30552167 DOI: 10.1136/neurintsurg-2018-014396] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/16/2018] [Accepted: 10/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Treatment of acute cerebrovascular pathology, such as acute ischemic stroke or intracranial aneurysms, presents a challenge if an extracranial or intracranial stent is required; immediate platelet inhibition is vital. To date, there is no standardized approach for antiplatelet inhibition in an acute setting. OBJECTIVE To report our preliminary experience and lessons learnt using cangrelor in acute neurointervention. METHODS A single-arm pilot study was performed to assess the safety and efficacy of cangrelor plus aspirin for platelet inhibition in patients who require acute stenting in the setting of neuroendovascular treatment. RESULTS Eight patients were enrolled between October 2017 and August 2018. Median age was 71 years (53-86). Seven patients were treated in an acute setting according to the stroke protocol at our institution, while one patient was treated for a symptomatic, unruptured aneurysm with flow diversion and coiling. At admission, the median National Institutes of Health Stroke Scale score for the patients with stroke was 12.5 (range 2-22.3). Cangrelor was infused and all patients achieved adequate platelet inhibition (<200 PRU (P2Y12 reaction units)). Six of seven patients with ischemic stroke had a carotid stent placed and one had an intracranial stent deployed in the middle cerebral artery. None of the patients experienced intraprocedural thromboembolic complications, intraprocedural in-stent thrombosis, hemorrhagic complications, or stroke within 24 hours after the intervention. The majority of patients (6/8) had a good clinical outcome at discharge (modified Rankin Scale score 0-2). CONCLUSIONS Our findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures.
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Affiliation(s)
- Pedro Aguilar-Salinas
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA.,Division of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | | | | | - Roberta Santos
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Manuel F Granja
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Douglas Gonsales
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Baptist Health, Jacksonville, Florida, USA
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10
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Price MJ. Cangrelor: Pharmacology, Clinical Data, and Role in Percutaneous Coronary Intervention. Interv Cardiol Clin 2018; 6:39-47. [PMID: 27886821 DOI: 10.1016/j.iccl.2016.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In clinical trials that assessed the safety and efficacy of cangrelor during percutaneous coronary intervention (PCI), cangrelor was administered as a 30-μg/kg bolus followed by a 4-μg/kg/min infusion for at least 2 hours or the duration of the PCI, whichever was longer. Cangrelor is currently indicated as an adjunct to PCI to reduce the risk of myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients who have not been treated with a P2Y12 platelet inhibitor and are not being given a glycoprotein IIb/IIIa inhibitor.
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Affiliation(s)
- Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, Suite AMP-200, La Jolla, CA 92037, USA.
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Fiore M, Gerbaud E, Coste P, Cetran L, Marchand H, Seguy B. Optimal platelet inhibition with cangrelor in comatose survivors of out-of-hospital cardiac arrest undergoing primary percutaneous coronary intervention. Resuscitation 2018; 130:e1-e2. [PMID: 29969644 DOI: 10.1016/j.resuscitation.2018.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 06/19/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Mathieu Fiore
- Laboratory of Hematology, Reference Center for Platelet Disorders, University Hospital of Bordeaux, Pessac, France.
| | - Edouard Gerbaud
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
| | - Pierre Coste
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
| | - Laura Cetran
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
| | - Hugo Marchand
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
| | - Benjamin Seguy
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
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Angiolillo DJ, Rollini F, Storey RF, Bhatt DL, James S, Schneider DJ, Sibbing D, So DY, Trenk D, Alexopoulos D, Gurbel PA, Hochholzer W, De Luca L, Bonello L, Aradi D, Cuisset T, Tantry US, Wang TY, Valgimigli M, Waksman R, Mehran R, Montalescot G, Franchi F, Price MJ. International Expert Consensus on Switching Platelet P2Y
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Receptor–Inhibiting Therapies. Circulation 2017; 136:1955-1975. [DOI: 10.1161/circulationaha.117.031164] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden (S.J.)
| | - David J. Schneider
- Department of Medicine, Cardiology Unit, Cardiovascular Research Institute, University of Vermont, Burlington (D.J.S.)
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Germany (D.S.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (D.S.)
| | - Derek Y.F. So
- Division of Cardiology, University of Ottawa Heart Institute, Ontario, Canada (D.Y.S.F.)
| | - Dietmar Trenk
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (D.T., W.H.)
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, National and Capodistrian University of Athens, Attikon University Hospital, Greece (D. Alexopoulos)
| | - Paul A. Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G., U.S.T.)
| | - Willibald Hochholzer
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (D.T., W.H.)
| | - Leonardo De Luca
- Division of Cardiology, Laboratory of Interventional Cardiology, San Giovanni Evangelista Hospital, Tivoli-Rome, Italy (L.D.L.)
- Mediterranean Academic Association for Research and Studies in Cardiology, Marseille, France (L.D.L.)
- Aix-Marseille University, INSERM UMRS 1076, Marseille, France (L.D.L.)
| | - Laurent Bonello
- Assistance Publique-Hôpitaux de Marseille, Department of Cardiology, Hôpital Nord, Marseille, France (L.B.)
| | - Daniel Aradi
- Heart Center Balatonfüred and Semmelweis University Budapest, Hungary (D. Aradi)
| | - Thomas Cuisset
- Department of Cardiology, CHU Timone, and Aix-Marseille Université, Faculté de Médecine, Marseille, France (T.C.)
| | - Udaya S. Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G., U.S.T.)
| | - Tracy Y. Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W.)
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Switzerland (M.V.)
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (R.W.)
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York City, NY (R.M.)
| | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, Hôpital Pitié-Salpêtrière, France (G.M.)
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
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Role of New Antiplatelet Drugs on Cardiovascular Disease: Update on Cangrelor. Curr Atheroscler Rep 2017; 18:66. [PMID: 27714642 DOI: 10.1007/s11883-016-0617-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Dual therapy with a P2Y12 receptor antagonist in addition to aspirin is the antiplatelet treatment of choice in patients with acute coronary syndromes or undergoing percutaneous coronary intervention (PCI). However, available oral P2Y12 antagonists have several limitations, mostly due to their pharmacological profile, which can affect outcomes in certain clinical settings. Cangrelor is an intravenous, direct-acting, potent P2Y12 inhibitor with rapid onset and offset of action, which has been recently approved for clinical use in patients undergoing PCI. In clinical trials, cangrelor has demonstrated greater efficacy than clopidogrel with a favorable safety profile among PCI patients not receiving pretreatment with oral P2Y12 antagonists. However, its definitive role in contemporary practice is yet to be determined. This review aims to provide a comprehensive overview of the current status of knowledge on cangrelor, focusing on its pharmacological properties, clinical development, and the potential applications of this newly available agent.
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Abstract
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.
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Switching of platelet P2Y12 receptor inhibitors in patients with acute coronary syndromes undergoing percutaneous coronary intervention: Review of the literature and practical considerations. Am Heart J 2016; 176:44-52. [PMID: 27264219 DOI: 10.1016/j.ahj.2016.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/03/2016] [Indexed: 11/22/2022]
Abstract
The combination of aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment in patients with acute coronary syndromes (ACSs) and in those undergoing percutaneous coronary intervention (PCI). At the present time, 3 different oral P2Y12 receptor inhibitors are available on the market; 2 have obtained the indication for ACS (clopidogrel and ticagrelor) and 1 for ACS with planned PCI (prasugrel). An intravenous direct acting P2Y12 inhibitor, cangrelor, has also been recently approved by US and European regulatory agencies for patients undergoing PCI. Although the correct timing and modality of transition from intravenous cangrelor to oral P2Y12 inhibitors is still controversial and needs further evidence, switching between oral P2Y12 receptor inhibitors frequently occurs in clinical practice for several reasons. This practice raises the question of the relative safety of this strategy and of which switching approaches are preferable. In this article, we review the data on switching antiplatelet treatment strategies with P2Y12 receptor inhibitors and discuss practical considerations for switching therapies in patients with ACS undergoing PCI.
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Sibbing D, Kastrati A, Berger PB. Pre-treatment with P2Y12inhibitors in ACS patients: who, when, why, and which agent? Eur Heart J 2015; 37:1284-95. [DOI: 10.1093/eurheartj/ehv717] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/06/2015] [Indexed: 12/22/2022] Open
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