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Martin TC, Duewell BE, Juul JJ, Rinka JRG, Rein L, Feih JT. Comparison of Outcomes in Patients Requiring Mechanical Circulatory Support Who Received Cangrelor in Addition to Anticoagulation Versus Anticoagulation Alone. J Cardiothorac Vasc Anesth 2024; 38:1328-1336. [PMID: 38521630 DOI: 10.1053/j.jvca.2024.02.039] [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] [Received: 10/11/2023] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES To evaluate the safety of cangrelor administered concurrently with heparin or bivalirudin in patients on mechanical circulatory support. DESIGN A single-center, retrospective cohort study of adult patients consecutively admitted between January 2016 and October 2020. SETTING A tertiary medical center. PARTICIPANTS Adult patients admitted to the cardiovascular intensive care unit put on mechanical circulatory support for acute myocardial infarction (AMI) or non-AMI indications. Patients who received cangrelor underwent percutaneous coronary intervention with stenting during the index event or within the last year. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was the incidence of major bleeding, defined by the Extracorporeal Life Support Organization criteria, in patients with mechanical circulatory support receiving cangrelor plus anticoagulation with heparin or bivalirudin with or without aspirin versus patients who did not receive cangrelor. Sixty-eight patients were included in the study. Twenty-nine patients received cangrelor, and 39 did not. Cangrelor was not associated with an increase in major bleeding; however, the CI was wide (adjusted hazard ratio 1.93, 95% CI 0.61-6.11; p = 0.262). CONCLUSIONS Patients receiving cangrelor did not appear to be at higher risk of major bleeding compared to patients not receiving cangrelor. Larger trials should be conducted to better evaluate the safety of cangrelor in patients with mechanical circulatory support.
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Affiliation(s)
- Trent C Martin
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI.
| | | | - Janelle J Juul
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI
| | - Joseph R G Rinka
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI; School of Pharmacy, Concordia University Wisconsin, Mequon, WI
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Joel T Feih
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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Connery A, Ahuja T, Katz A, Arnouk S, Zhu E, Papadopoulos J, Rao S, Merchan C. Antithrombotic Stewardship: Evaluation of Platelet Reactivity-Guided Cangrelor Dosing Using the VerifyNow Assay. J Cardiovasc Pharmacol 2024; 83:482-489. [PMID: 38335531 DOI: 10.1097/fjc.0000000000001543] [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] [Received: 11/09/2023] [Accepted: 12/23/2023] [Indexed: 02/12/2024]
Abstract
ABSTRACT Cangrelor may be used as a bridge when temporary interruption of dual antiplatelet therapy is necessary. However, the optimal dose and monitoring of cangrelor in patients remains unknown, especially in the setting of mechanical circulatory support (MCS). We conducted an observational, single-center, retrospective cohort study of patients who had percutaneous coronary intervention within 3 months and received cangrelor while admitted to any intensive care unit. The primary outcome was the incidence of any major adverse cardiovascular event. Secondary outcomes included VerifyNow platelet reactivity units (PRUs) measured while on cangrelor and any bleeding events while on cangrelor. A total of 92 patients were included. The most common reason for cangrelor use was in the periprocedural setting, with or without MCS (42%-45%), followed by NPO status (26%-28%) and MCS alone (22%-24%). The primary outcome of major adverse cardiovascular event occurred in 1 patient (1.1%). Of 92 patients, 77% had a P2Y12 level collected within 24 hours, and 89% of the cohort was able to achieve the goal P2Y12 PRU of <194. The median P2Y12 value within 24 hours of cangrelor initation was 115 PRU (40-168 PRU). We observed a bleed event rate of 23% (21/92). We found a standardized protocol of cangrelor dosing in critically ill patients who received a drug-eluting stent in the past 3 months to be successful in achieving a goal P2Y12 PRU. Although the optimal PRU remains unknown, cardiovascular clinicians may monitor these levels to help guide decisions regarding cangrelor management. Future randomized controlled trials should evaluate the optimal PRU threshold to balance risks of ischemia and bleeding.
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Affiliation(s)
| | - Tania Ahuja
- Department of Pharmacy, NYU Langone Health, New York, NY
- Department of Medicine, NYU Grossman School of Medicine, New York, NY; and
| | - Alyson Katz
- Department of Pharmacy, NYU Langone Health, New York, NY
| | - Serena Arnouk
- Department of Pharmacy, NYU Langone Health, New York, NY
| | - Eric Zhu
- Beth Israel Deaconess Medical Center, Boston
| | - John Papadopoulos
- Department of Pharmacy, NYU Langone Health, New York, NY
- Department of Medicine, NYU Grossman School of Medicine, New York, NY; and
| | - Sunil Rao
- Department of Medicine, NYU Grossman School of Medicine, New York, NY; and
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Buck MM, Barry CI, Montepara CA, Verlinden NJ. Platelet Function Testing to Guide Cangrelor Dosing in Patients with Temporary Mechanical Circulatory Support or as a Bridge to Procedure. Clin Appl Thromb Hemost 2024; 30:10760296241237228. [PMID: 38439661 PMCID: PMC10916455 DOI: 10.1177/10760296241237228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024] Open
Abstract
Cangrelor is a rapid-acting, intravenous P2Y12 inhibitor that can be used in patients after percutaneous coronary intervention who require mechanical circulatory support or as a bridge to procedure. We retrospectively reviewed adult patients who received platelet function testing (PFT) with the VerifyNow P2Y12 assay while on cangrelor from March 2021 through November 2022. All patients were initiated on 0.75 mcg/kg/min of cangrelor with P2Y12 reaction unit (PRU) values collected 12-24 h after initiation. Cangrelor doses were adjusted per protocol to maintain PRU values of 85-208. A total of 42 patients were included. Thirty-eight patients (90.5%) required temporary mechanical circulatory support while on cangrelor, and 4 patients (9.5%) received cangrelor as a bridge to procedure. The median cangrelor maintenance dose was 0.5 (interquartile range [IQR]: 0.375-0.75) mcg/kg/min, and the median time in therapeutic range with a PRU value between 85 and 208 was 66.6% (IQR: 39.6%-100%). No patients experienced stent thrombosis. A composite major adverse cardiovascular event occurred in 4 patients (9.5%), and major bleeding occurred in 16 patients (38.1%). Compared to empiric cangrelor dosing of 0.75 mcg/kg/min, PFT-guided cangrelor dose adjustment was associated with a median drug cost savings of $1605.60 (IQR: $0-4281.56). Utilizing PFT with cangrelor may allow for lower, individualized dosing while preventing stent thrombosis.
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Affiliation(s)
- Margaret M. Buck
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Chelsea I. Barry
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Courtney A. Montepara
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA
- Duquesne University School of Pharmacy, Pittsburgh, PA, USA
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Tang S, Xu L, Li H, Wu Z, Wen Q. Anticoagulants in adult extracorporeal membrane oxygenation: alternatives to standardized anticoagulation with unfractionated heparin. Eur J Clin Pharmacol 2023; 79:1583-1594. [PMID: 37740749 DOI: 10.1007/s00228-023-03568-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/14/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a vital technique for severe respiratory or heart failure patients. Bleeding and thrombotic events are common during ECMO and negatively impact patient outcomes. Unfractionated heparin is the primary anticoagulant, but its adverse effects limit its use, necessitating alternative anticoagulants. OBJECTIVE Review available alternative anticoagulants for adult ECMO patients. Explore potential novel anticoagulants for future ECMO use. Aim to reduce complications (bleeding and thrombosis) and improve safety and efficacy for critically ill ECMO patients. METHODS Comprehensive literature review of existing and emerging anticoagulants for ECMO. RESULTS Identified a range of alternative anticoagulants beyond unfractionated heparin. Evaluated their potential utility in mitigating ECMO-related complications. CONCLUSION Diverse anticoagulant options are available and under investigation for ECMO. These alternatives may enhance patient safety and outcomes during ECMO support. Further research and clinical studies are warranted to determine their effectiveness and safety profiles.
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Affiliation(s)
- Shu Tang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Liqing Xu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui Li
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhanshen Wu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiang Wen
- Institute of Clinical Pharmacology, Zhengzhou University, Zhengzhou, China
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Pluenneke JC, Mohamed AM, Hayes CH, Berry TP, Thomas EL, Zhurav L, Kozinn JB, Haines MM, Welge JA. Evaluation of Cangrelor Use After Percutaneous Coronary Intervention in Patients With Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2023; 37:2511-2516. [PMID: 37775345 DOI: 10.1053/j.jvca.2023.08.153] [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] [Received: 07/02/2023] [Revised: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVES To describe cangrelor use in patients on concurrent mechanical circulatory support who underwent postpercutaneous coronary intervention. DESIGN A single-center, retrospective, cohort study. SETTING At a quaternary teaching hospital. PARTICIPANTS Included patients were ≥18 years old, admitted to the intensive care unit, underwent percutaneous coronary intervention with stent placement, initiated on mechanical circulatory support, and received cangrelor in the postpercutaneous coronary intervention period. INTERVENTIONS Retrospectively analyzed cangrelor use in patients on mechanical circulatory support. MEASUREMENTS AND MAIN RESULTS The primary outcome was the incidence of thrombosis and bleeding events during cangrelor administration. Additional outcomes included initial cangrelor dose, number of cangrelor dose adjustments per patient, survival from mechanical circulatory support, and mortality within 30 days. Overall, 19 patients were included in this study. In total, 14 patients (74%) experienced a bleeding event; however, 93% were classified as a minor bleed. There was 1 major bleeding event. There were no thrombotic events observed during cangrelor administration. The median initial cangrelor dose was 0.5 µg/kg/min. There were 10 patients who underwent dose adjustment, with the majority being dose reductions based on antiplatelet monitoring (VerifyNow assay). Survival from mechanical circulatory support occurred in 17 patients (89%), and 30-day mortality occurred in 8 patients (42%). CONCLUSIONS For patients receiving cangrelor as a bridge to oral P2Y12 inhibitor therapy on mechanical circulatory support, the authors observed a low rate of major bleeding and no episodes of thrombosis. Lower starting doses appear feasible with no observed increased risk of thrombotic complications. Future studies are needed to confirm these observations.
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Affiliation(s)
- Jack C Pluenneke
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO.
| | - Adham M Mohamed
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Charles H Hayes
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Timothy P Berry
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Elizabeth L Thomas
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Larisa Zhurav
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, School of Medicine, Kansas City, MO
| | - Jonathan B Kozinn
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, School of Medicine, Kansas City, MO
| | - Michelle M Haines
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, School of Medicine, Kansas City, MO
| | - Julie A Welge
- Department of Pharmacy, Saint Luke's Hospital of Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
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Cohan D, Uricchio MN, Konopka CI, Montepara CA, Verlinden NJ. Comparison of clinical outcomes with cangrelor plus aspirin versus oral dual antiplatelet therapy in patients supported with venoarterial extracorporeal membrane oxygenation. Artif Organs 2023; 47:1672-1677. [PMID: 37203212 DOI: 10.1111/aor.14590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/22/2023] [Accepted: 05/13/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Patients with refractory cardiogenic shock from an acute myocardial infarction may receive percutaneous coronary intervention (PCI) and require the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO). The purpose of this study was to compare bleeding and thrombotic events in patients treated with cangrelor plus aspirin versus oral dual antiplatelet therapy (DAPT) while supported with VA-ECMO. METHODS We conducted a retrospective review of patients who received PCI, were supported with VA-ECMO, and were treated with either cangrelor plus aspirin or oral DAPT from February 2016 through May 2021 at Allegheny General Hospital. The primary objective was the incidence of major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or greater. The incidence of thrombotic events was a secondary objective. RESULTS Thirty-seven patients were included, 19 in the cangrelor plus aspirin group, and 18 in the oral DAPT group. All the patients in the cangrelor group received a dose of 0.75 mcg/kg/min. Major bleeding occurred in 7 patients (36.8%) in the cangrelor group compared to 7 patients (38.9%) in the oral DAPT group (p = 0.90). No patient developed stent thrombosis. Two patients (10.5%) in the cangrelor group had a thrombotic event versus 3 patients (16.7%) in the oral DAPT group (p = 0.66). CONCLUSIONS Bleeding and thrombotic events were comparable between patients receiving cangrelor plus aspirin versus oral DAPT while on VA-ECMO.
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Affiliation(s)
- Dana Cohan
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, Virginia, USA
| | - Marissa N Uricchio
- Department of Pharmacy, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Chelsea I Konopka
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Courtney A Montepara
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Nathan J Verlinden
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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Rajsic S, Breitkopf R, Rugg C, Bukumiric Z, Reitbauer J, Treml B. Thrombotic Events Develop in 1 Out of 5 Patients Receiving ECMO Support: An 11-Year Referral Centre Experience. J Clin Med 2023; 12:jcm12031082. [PMID: 36769730 PMCID: PMC9917555 DOI: 10.3390/jcm12031082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/28/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) for critically ill patients is growing rapidly given recent developments in technology. However, adverse events are frequently reported that have potentially devastating impacts on patient outcomes. The information on predictors and risk factors for thrombotic events, especially that focusing on the comparison of veno-arterial and veno-venous ECMO configurations, are still inconsistent and sparse; therefore, we aimed to close this gap. METHODS We performed a retrospective analysis of all patients on extracorporeal life support admitted to the intensive care units of a tertiary university center in Europe. RESULTS From 645 patients, 417 who received extracorporeal life support due to cardiogenic shock (290, 70%), respiratory failure (116, 28%) or hypothermia (11, 3%) were included. In total, 22% (92) of the patients experienced thrombotic events with a similar incidence in both ECMO configurations. Anticoagulation consisted of unfractionated heparin (296, 71%) and argatroban (70, 17%). Univariate Cox analyses identified hemoconcentration and increased maximal clot firmness (thromboelastometry) as risk factors for thrombosis. Moreover, the patients experiencing thrombosis had longer ECMO duration and intensive care stays. CONCLUSIONS ECMO is a specialized life-support modality with a high risk of complications. A longer ECMO duration is associated with thrombosis occurrence in patients receiving ECMO support. Following hemorrhage, thromboembolic complications are common adverse events. However, in contrast to major bleeding, no impact on mortality was observed. The question arises if a protocol with less anticoagulation may have a role to play in the future.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Christopher Rugg
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Jakob Reitbauer
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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Iskaros O, Ahuja T, Arnouk S, Toy B, Lewis T, Altshuler D, Smith D, Papadopoulos J, Merchan C. Antithrombotic management for Impella ® temporary ventricular assist devices: An analysis of an academic health-system experience. Int J Artif Organs 2022; 45:550-559. [PMID: 35285339 DOI: 10.1177/03913988221082686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The use of acute mechanical circulatory support (MCS) has increased over the last decade. For patients with left-ventricular failure, an Impella® (Abiomed, Danvers, MA) may be used to improve cardiac output. The purpose of this study is to describe Impella® anticoagulation patterns and evaluate the safety and effectiveness of our protocol. This is a retrospective review of all adult patients who required at least 24 h of Impella® support and received a heparin-based purge solution. In total, 109 patients were included in the final analysis. The most common indication for Impella® device insertion was cardiogenic shock (76%) with the remaining patients receiving a device for a high-risk procedures; typically coronary artery bypass grafting or percutaneous coronary intervention. A total of 9 thrombotic events occurred among 8 (7%) patients and 50 bleeding events occurred among 43 (39%) patients, with the most common classification being BARC 3a (60%). A univariate analysis revealed that patients were more likely to bleed if they were less than 65 years old, had an indication of cardiogenic shock for Impella®, inserted the device peripherally, were on dual antiplatelet therapy, or had an intra-aortic balloon pump prior to Impella® insertion, the latter of which was confirmed with a multivariate analysis (OR 2.5 [1.072-5.830]; p = 0.034). For those monitored by anti-Xa, the presence of two or more values greater than 0.40 IU/mL was a risk factor for bleeding (p = 0.037). Our study identifies risk factors for bleeding in patients receiving temporary MCS with an Impella®.
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Affiliation(s)
| | - Tania Ahuja
- New York University Langone Health, New York, NY, USA
| | - Serena Arnouk
- New York University Langone Health, New York, NY, USA
| | - Bridget Toy
- New York University Langone Health, New York, NY, USA
| | - Tyler Lewis
- New York University Langone Health, New York, NY, USA
| | | | - Deane Smith
- New York University Langone Health, New York, NY, USA
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