Cangrelor in Percutaneous Coronary Intervention: Current Status and Perspectives

Comparative effectiveness of Cangrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: an observational investigation from the M.O.Ca. registry

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.

Inhibition of GPR17 with cangrelor improves cognitive impairment and synaptic deficits induced by Aβ1-42 through Nrf2/HO-1 and NF-κB signaling pathway in mice

The accumulation of amyloid beta (Aβ) in the brain is thought to be associated with cognitive deficits in Alzheimer's disease (AD). However, current methods to combat Aβ neurotoxicity are still lacking. G protein-coupled receptor 17 (GPR17) has become a target for treating inflammation in brain diseases, but it is unclear whether it has a role in AD. Here, we investigated the effects of cangrelor, a GPR17 antagonist, on neurotoxicity and memory impairment induced by intracerebroventricular (i.c.v.) injection of Aβ_1-42 in mice. The behavior results showed that cangrelor (2.0 or 4.0 μg/mouse, i.c.v.) treatment reversed the deficits in memory and learning ability induced by Aβ_1-42 in mice. Importantly, we demonstrated for the first time that GPR17 expression in the hippocampus and frontal cortex is increased in response to Aβ_1-42 exposures. We also found that cangrelor treatment reduced the activity of β-secretase 1 (BACE1) and the levels of soluble Aβ_1-42 in the hippocampus and frontal cortex. Meanwhile, cangrelor treatment suppressed oxidative stress induced by Aβ_1-42, as proved by reduced production of malondialdehyde (MDA), and increased glutathione (GSH), superoxide dismutase (SOD), and catalase (CAT), and promoted the expression of nuclear factor E2-related factor 2 (Nrf2) and heme oxygenase 1 (HO-1). Furthermore, cangrelor also suppressed Aβ_1-42-induced neuroinflammation, characterized by suppressed activation of microglia, decreased the levels of pro-inflammatory cytokines, and nuclear translocation of NF-κB p65, as well as ameliorated synaptic deficits by promoting the upregulation of synaptic proteins, and increasing the number of Golgi-Cox stained dendritic spines. These results suggest that cangrelor may reverse Aβ_1-42-induced cognition deficits via inhibiting oxidative stress, neuroinflammation, and synaptic dysfunction mediated by Nrf2/HO-1 and NF-κB signaling.

Clinical use of cangrelor: a real world multicenter experience from South Italy Insights from the M.O.Ca. registry

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.

Antithrombotic treatment in primary percutaneous coronary intervention

INTRODUCTION

Despite a timely mechanical reperfusion with primary percutaneous coronary intervention (pPCI) patients presenting with ST-elevation myocardial infarction (STEMI) display an increased risk of adverse cardiovascular events. Several studies have demonstrated that guideline-directed antithrombotic therapy is effective to reduce this risk. However, there is still much to be accomplished to improve antithrombotic therapies in this clinical setting.

AREAS COVERED

This paper reviews current data on antithrombotic therapy in STEMI patients undergoing pPCI.

EXPERT OPINION

Antithrombotic therapy for STEMI patients undergoing pPCI should take into account the variability of thrombotic and bleeding risk in the short and long term. Patients with STEMI profit from the administration of early onset antiplatelet agents and anticoagulation to achieve sufficient and predictable antithrombotic effect at the time of pPCI. Thereafter, antithrombotic therapies should be tailored to individual risk of recurrence over the long term, to avoid excess bleeding, while ensuring adequate secondary ischemic prevention.

Adenosine Receptor Agonist HE-NECA Enhances Antithrombotic Activities of Cangrelor and Prasugrel in vivo by Decreasing of Fibrinogen Density in Thrombus

Blood platelets' adenosine receptors (AR) are considered to be a new target for the anti-platelet therapy. This idea is based on in vitro studies which show that signaling mediated by these receptors leads to a decreased platelet response to activating stimuli. In vivo evidence for the antithrombotic activity of AR agonists published to date were limited, however, to the usage of relatively high doses given in bolus. The present study was aimed at verifying if these substances used in lower doses in combination with inhibitors of P2Y12 could serve as components of dual anti-platelet therapy. We have found that a selective A2A agonist 2-hexynyl-5'-N-ethylcarboxamidoadenosine (HE-NECA) improved the anti-thrombotic properties of either cangrelor or prasugrel in the model of ferric chloride-induced experimental thrombosis in mice. Importantly, HE-NECA was effective not only when applied in bolus as other AR agonists in the up-to-date published studies, but also when given chronically. In vitro thrombus formation under flow conditions revealed that HE-NECA enhanced the ability of P2Y12 inhibitors to decrease fibrinogen content in thrombi, possibly resulting in their lower stability. Adenosine receptor agonists possess a certain hypotensive effect and an ability to increase the blood-brain barrier permeability. Therefore, the effects of anti-thrombotic doses of HE-NECA on blood pressure and the blood-brain barrier permeability in mice were tested. HE-NECA applied in bolus caused a significant hypotension in mice, but the effect was much lower when the substance was given in doses corresponding to that obtained by chronic administration. At the same time, no significant effect of HE-NECA was observed on the blood-brain barrier. We conclude that chronic administration of the A2A agonist can be considered a potential component of a dual antithrombotic therapy. However, due to the hypotensive effect of the substances, dosage and administration must be elaborated to minimize the side-effects. The total number of animals used in the experiments was 146.

New Antithrombotic Drugs in Acute Coronary Syndrome

In recent years, much progress has been made in the field of antithrombotic drugs in acute coronary syndrome (ACS) treatment, as reflected by the introduction of the more potent P2Y12-inhibitors prasugrel and ticagrelor, and novel forms of concomitant anticoagulation, such as fondaparinux and bivalirudin. However, despite substantial improvements in contemporary ACS treatment, there remains residual ischemic risk in this group and hence the need for even more effective antithrombotic drugs, while balancing antithrombotic efficacy against bleeding risk. This review discusses recently introduced and currently developed antiplatelet and anticoagulant drugs in ACS treatment.

P2Y12 inhibitors for the treatment of acute coronary syndrome patients undergoing percutaneous coronary intervention: current understanding and outcomes

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.

Preliminary Experience with Cangrelor for Endovascular Treatment of Challenging Intracranial Aneurysms

BACKGROUND AND PURPOSE

Cangrelor is a P2Y12 inhibitor that presents the advantage of having a short half-life. Its use may be helpful in the management of antiplatelet therapy for patients with intracranial aneurysms treated by stent-assisted coiling or flow-diverter stents. The purpose of this study was to report early experiences in using cangrelor for such indications.

MATERIAL AND METHODS

From October 2017 to November 2018, 7 consecutive patients (5 females, 2 males, mean age = 56 years) were managed with cangrelor as antiplatelet therapy, combined with aspirin, for stent-assisted coiling embolization and flow-diverter embolization of challenging intracranial aneurysms. Anti-aggregation protocols, including cangrelor, were systematically recorded. Treatment-related complications (minor/major hemorrhagic complications, ischemic complications) as well as clinical and angiographic outcomes (evaluated at 8.7 ± 4.2 and 8.75 ± 10 months, respectively) were retrospectively analyzed.

RESULTS

Of the aneurysms 71.4% (5 out of 7) were ruptured and treated in the acute phase. In one case cangrelor was used as an alternative to clopidogrel in an asymptomatic hemorrhagic complication after stent-assisted coiling for better control of a possible worsening of the intracranial bleeding. Of the patients, 1 (14%) with a complex ruptured MCA aneurysm treated with a flow-diverter stent experienced a severe intracranial hemorrhage, which occurred after switching the cangrelor to ticagrelor and eventually led to death. No hemorrhagic complications under cangrelor were recorded for the six remaining patients. No mRS worsening was observed at discharge, except for the patient who died and six out of the seven patients had a mRS ≤2 at follow-up.

CONCLUSION

Cangrelor is a new antiplatelet therapy with a P2Y12 inhibiting effect, with a rapid onset and offset of action, owing to its short half-life. This cases series presents a pilot experience with promising results in terms of antiplatelet management for challenging intracranial aneurysms treated by stent assisted coiling or flow-diverter stents.

Proton Pump Inhibition in Patients Treated With Novel Antithrombotic Drugs: Should We Worry About Thrombosis?

Proton pump inhibition (PPI) administered together with antiplatelet and anticoagulant agents reduces the risk of gastrointestinal hemorrhage. Several novel antithrombotic agents have been recently introduced for patients with acute coronary syndrome (prasugrel and ticagrelor) or for patients requiring long-term anticoagulation (dabigatran, rivaroxaban, apixaban, edoxaban, and betrixaban). In fact, these agents might offer even stronger inhibition of platelets or coagulation compared with older agents; therefore, the need for gastroprotection might be even stronger when these new agents are used for long-term antithrombotic therapy. On the contrary, there are several reports regarding an adverse interaction between PPI and antithrombotic agents connected with a reduction in antithrombotic therapy on-treatment levels, implicating a higher risk of thrombosis. This interaction was demonstrated in clopidogrel-treated patients and more recently also in dabigatran-treated patients. This article discusses a possible novel antithrombotic therapy/PPI interaction leading to higher risk of thrombosis.

Cangrelor or Clopidogrel in Patients with Type 2 Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

With recent advances in interventional cardiology where percutaneous coronary intervention (PCI) has become the most preferred invasive strategy and with advances in adjunctive pharmacotherapy, several newer oral P2Y₁₂ inhibitors have reached the market. In this analysis, we aimed to compare the cardiovascular outcomes and bleeding events which were associated with the use of cangrelor versus clopidogrel in patients with type 2 diabetes mellitus (T2DM) 48 h after PCI.

METHODS

The electronic databases MEDLINE (PubMed), www.ClinicalTrials.gov , EMBASE, and Cochrane central were searched for relevant publications comparing canagrelor with clopidogrel during PCI. Patients with T2DM were extracted. Adverse cardiovascular outcomes and bleeding events at 48 h follow-up were considered as the end points. This meta-analysis was carried out with the latest RevMan software (5.30). Odds ratios (OR) and 95% confidence intervals (CI) were used to represent the data.

RESULTS

This analysis consisted of a total number of 5031 participants with T2DM (enrolled between the years 2006 and 2012). Compared to clopidgrel, use of cangrelor in these patients with T2DM was not associated with significantly different primary end point (OR 0.94, 95% CI 0.75-1.16; P = 0.55), myocardial infarction (OR 0.96, 95% CI 0.76-1.20; P = 0.71), all-cause death (OR 0.70, 95% CI 0.25-1.96; P = 0.49), ischemia-driven revascularization (OR 0.66, 95% CI 0.32-1.36; P = 0.26), and stent thrombosis (OR 0.45, 95% CI 0.17-1.17; P = 0.10). Thrombolysis in myocardial infarction (TIMI)-defined major and minor bleedings were similarly manifested: (OR 1.02, 95% CI 0.38-2.74; P = 0.96) and (OR 1.39, 95% CI 0.70-2.79; P = 0.35), respectively. Global use of strategies to open occluded arteries (GUSTO)-defined moderate and severe bleeding were also not significantly different: (OR 1.36, 95% CI 0.70-2.67; P = 0.37) and (OR 1.21, 95% CI 0.41-3.59; P = 0.74), respectively. However, GUSTO-defined mild bleeding and acute catheterization and urgent intervention triage strategy (ACUITY)-defined major and minor bleedings were significantly in favor of clopidogrel in comparison to cangrelor in these patients with T2DM: (OR 1.28, 95% CI 1.09-1.50; P = 0.003), (OR 1.43, 95% CI 1.05-1.94; P = 0.02), and (OR 1.23, 95% CI 1.04-1.46; P = 0.02), respectively. Other bleeding outcomes were not significantly different.

CONCLUSIONS

In these patients with T2DM, cangrelor was comparable to clopidogrel in terms of efficacy at 48 h following PCI. However, it was associated with significantly higher mild GUSTO bleeding and major and minor ACUITY bleeding, therefore requiring further workups on its safety side. This hypothesis should be explored further and confirmed in other forthcoming trials based strictly on patients with T2DM.

Periprocedural Neuroendovascular Antiplatelet Strategies for Thrombosis Prevention in Clopidogrel-Hyporesponsive Patients

Patients undergoing neuroendovascular procedures such as cerebral aneurysm coiling and intracranial stent deployment are frequently treated with antiplatelet agents to prevent thrombotic complications. The combination of aspirin and a P2Y12 inhibitor such as clopidogrel is often initiated days before elective procedures or as loading doses for emergent procedures; however, some patients may still experience thrombotic complications. Patients identified as clopidogrel hyporesponders are more likely to experience poor outcomes and may require changes to their regimens. Historically, high-dose clopidogrel regimens were used in response to subtherapeutic results of platelet function assays and point-of-care testing despite limited supporting data. Recently, more data have emerged using alternative P2Y12 inhibitors such as prasugrel and ticagrelor. Dosing for neuroendovascular conditions is often extrapolated from the cardiac literature, although outcomes in cardiac patients may not be relevant to neurologic patients, making prophylactic treatment recommendations challenging for these patients. This review summarizes the literature for antiplatelet prophylaxis in patients undergoing neuroendovascular device placement, focusing on alternative regimens for clopidogrel hyporesponders.