A Safety Evaluation of Cangrelor in Patients Undergoing PCI

Dual Antiplatelet Therapy with Parenteral P2Y12 Inhibitors: Rationale, Evidence, and Future Directions

Dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and an inhibitor of the platelet P2Y₁₂ receptor for ADP, remains among the most investigated treatments in cardiovascular medicine. While a substantial amount of research initially stemmed from the observations of late and very late stent thrombosis events in the first-generation drug-eluting stent (DES) era, DAPT has been recently transitioning from a purely stent-related to a more systemic secondary prevention strategy. Oral and parenteral platelet P2Y₁₂ inhibitors are currently available for clinical use. The latter have been shown to be extremely suitable in drug-naïve patients with acute coronary syndrome (ACS), mainly because oral P2Y₁₂ inhibitors are associated with delayed efficacy in patients with STEMI and because pre-treatment with P2Y₁₂ inhibitors is discouraged in NSTE-ACS, and in patients with recent DES implantation and in need of urgent cardiac and non-cardiac surgery. More definitive evidence is needed, however, about optimal switching strategies between parenteral and oral P2Y₁₂ inhibitors and about newer potent subcutaneous agents that are being developed for the pre-hospital setting.

Cangrelor: Clinical Data, Contemporary Use, and Future Perspectives

Cangrelor is the only currently available intravenous platelet P2Y₁₂ receptor inhibitor. It is characterized by potent, predictable, and rapidly reversible antiplatelet effects. Cangrelor has been tested in the large CHAMPION (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) program, where it was compared with different clopidogrel regimens, and it is currently indicated for use in patients with coronary artery disease undergoing percutaneous coronary intervention. However, the uptake of cangrelor use varies across the globe and may also include patients with profiles different from those enrolled in the registration trials. These observations underscore the need to fully examine the safety and efficacy of cangrelor in postregistration studies. There are several ongoing and planned studies evaluating the use of cangrelor in real‐world practice which will provide important insights to this extent. The current article provides a review on the pharmacology, clinical studies, contemporary use of cangrelor in real‐world practice, a description of ongoing studies, and futuristic insights on potential strategies on how to improve outcomes of patients undergoing percutaneous coronary intervention.

Tackling the gap in platelet inhibition with oral antiplatelet agents in high-risk patients undergoing percutaneous coronary intervention

Introduction: Oral P2Y₁₂ inhibitors represent the mainstay therapy for the prevention of thrombotic complications in patients presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI). However, the onset of antiplatelet action of the oral P2Y₁₂ inhibitors is affected by their need to be absorbed in the gastrointestinal (GI) tract before becoming systemically available.Areas covered: Following oral intake of P2Y₁₂ inhibitors, the timeframe required for GI absorption leads to a window of inadequate antiplatelet protection during which patients are at increased thrombotic risk. The onset of action of the oral P2Y₁₂ inhibitors is even further delayed in high-risk patients, underscoring the need to define strategies to bridge the gap in platelet inhibitory effects following their intake.Expert opinion: Multiple mechanisms may impair GI absorption leading to a delay in the onset of action of oral P2Y₁₂ inhibitors. Several strategies have been tested to overcome the gap in platelet inhibition in high-risk patients undergoing PCI. These include administration of crushed or chewed tablets to improve the dissolution rate and use of opioid receptor antagonists or metoclopramide to counteract impairment of gastric motility induced by opioids. However, intravenous antiplatelet therapies represent the most effective strategy to bridge such gap in platelet inhibition.

Switching P2Y12 Receptor Inhibiting Therapies

Antiplatelet therapy with aspirin and a P2Y₁₂ receptor inhibitor is the cornerstone of treatment of patients with atherothrombotic disease manifestations. Switching between P2Y₁₂ inhibitors occurs commonly in clinical practice for a variety of reasons, including safety, efficacy, adherence, and economic considerations. There are concerns about the optimal approach for switching because of potential drug interactions, which may lead to ineffective platelet inhibition and thrombotic complications, or potential overdosing due to overlap in drug therapy, which might cause excessive platelet inhibition and increased bleeding. This review provides practical considerations of switching based on pharmacodynamic and clinical data available from the literature.

Antiplatelet and anticoagulation therapy during percutaneous coronary interventions: A review for the interventionalist

Pharmacotherapy for percutaneous coronary interventions is essential to optimize the balance between thrombosis and bleeding. Currently, choices abound for the selection of antiplatelet and anticoagulation therapies during percutaneous intervention (PCI). This review article discusses the mechanisms, pharmacokinetics/dynamics, and clinical data behind the various pharmacotherapies including; aspirin, thienopyridines, glycoprotein IIb/IIIa inhibitors, vorapaxar, heparin, direct thrombin inhibitors, and factor Xa inhibitors.

Acute coronary syndromes

In the UK, there are over 80,000 admissions annually with acute coronary syndromes (ACS). Management of ST-elevation myocardial infarction (STEMI) involves primary percutaneous coronary intervention (PCI), which is delivered via dedicated heart attack centres. Non-ST elevation-ACS (NSTE-ACS) accounts for two-thirds of ACS presentations, affecting an older cohort of patients - often with more complex comorbidities. Initial management is with anti-thrombotic therapy with a view to PCI within 24 hours for the most acute cases and within 72 hours for all others. However, varying management pathways and access to specialist cardiology services results in variable times to definitive treatment. Advances in the sensitivity of cardiac biomarkers and the use of risk assessment tools now enable rapid diagnosis within a few hours of symptom onset. Advances in invasive management and drug therapy have resulted in improved clinical outcomes with resultant decline in mortality associated with ACS.

Pretreatment with Antiplatelet Agents in the Setting of Percutaneous Coronary Intervention: When and Which Drugs?

Administering antiplatelet agents before coronary angiography to patients referred to elective or urgent percutaneous coronary intervention (PCI) requires a careful evaluation of advantages and disadvantages associated with platelet inhibition to avoid overtreatment on one side and undertreatment on the other. The delicate balance between ischemic protection and bleeding demands the ability to undertake risk stratification and individualized decisions, which is particularly challenging in the setting of ad hoc PCI and urgent procedures. This review analyzes the current evidence on pretreatment with oral and intravenous P2Y₁₂ inhibitors in patients undergoing coronary angiography with intent to undergo PCI.