Intravenous cangrelor as a peri-procedural bridge with applied uses in ischemic events

Antithrombotic Stewardship: Evaluation of Platelet Reactivity-Guided Cangrelor Dosing Using the VerifyNow Assay

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.

Antiplatelet Therapy in Atherothrombotic Diseases: Similarities and Differences Across Guidelines

Antiplatelet therapy, mainly consisting of aspirin and P2Y₁₂ receptor antagonists, is the cornerstone of the pharmacological treatment and prevention of atherothrombotic diseases. Its use, especially in secondary cardiovascular prevention, has significantly improved patient clinical outcomes in the last decades. Primary safety endpoint (i.e., bleeding complications) remain a major drawback of antiplatelet drugs. National and international societies have published and regularly updated guidelines for antiplatelet therapy aiming to provide clinicians with practical recommendations for a better handling of these drugs in various clinical settings. Many recommendations find common ground between international guidelines, but certain strategies vary across the countries, particularly with regard to the choice of molecules, dosage, and treatment duration. In this review, we detail and discuss the main antiplatelet therapy indications in the light of the different published guidelines and the significant number of recently published clinical trials and meta-analyses and highlight the areas that deserve further investigation in order to improve antiplatelet therapy in patients with atherothrombotic diseases.

Perioperative cangrelor in patients with recent percutaneous coronary intervention undergoing liver transplantation: A case series

BACKGROUND

Management of dual antiplatelet therapy (DAPT) in the perioperative setting is challenging, particularly in complex patient populations, such as those with underlying coagulopathy and/or recent percutaneous coronary interventions.

METHODS

In this case series, we describe the perioperative use of cangrelor bridge therapy in two patients undergoing liver transplantation after recent coronary drug-eluting stent placement.

OUTCOMES

In both patient cases, cangrelor use as a P2Y12 bridge at a dose of 0.75 μg/kg/min was safe and effective. Both patients were successfully switched back to their oral DAPT regimen post-operatively without additive bleeding or thrombotic complications.

CONCLUSION

The use of cangrelor as bridge therapy in high-risk perioperative liver transplant patients appears to be a viable option when DAPT is warranted.

The Role and Molecular Mechanism of P2Y12 Receptors in the Pathogenesis of Atherosclerotic Cardiovascular Diseases

The P2Y receptor family is a class of G protein-coupled receptors activated primarily by adenosine triphosphate (ATP), adenosine diphosphate (ADP), uridine triphosphate (UTP) and uridine diphosphate (UDP). The P2Y12 receptor is expressed on platelets which mediates platelet aggregation and morphological changes. At the same time, during the process of vascular remodeling and atherosclerosis, ADP can also promote the migration and proliferation of vascular smooth muscle and endothelial cells through P2Y12 receptor activating. Furthermore, P2Y12 is involved in many signal transductions processes, such as intimal hyperplasia, monocyte infiltration and so on, which play an important role in immune inflammation and brain injury. In order to solve the diseases induced by P2Y12 receptor, inhibitors such as ticagrelor, clopidogrel were widely used for cardiovascular diseases. However, there were some problems, such as limited antithrombotic effect, remain unsolved. This article summarizes the role and molecular mechanism of P2Y12 receptors in the pathogenesis of cardiovascular-related diseases, providing in-depth expounding on the molecular mechanism of P2Y12 receptor inhibitors and contributing to the treatment of diseases based on P2Y12 receptors.

Stroke Rates Following Surgical Versus Percutaneous Revascularization for Ischemic Heart Disease

PURPOSE OF REVIEW

Coronary revascularization is a commonly performed major procedure in the hospitals. Stroke is one of the dreaded complications after coronary revascularization procedures. The focus of this review is to understand the stroke risk in percutaneous cutaneous intervention (PCI) and coronary artery bypass grafting (CABG) procedures.

RECENT FINDINGS

Available data show that PCI offers less procedural stroke risk compared to CABG although the survival benefits of CABG are better in certain scenarios. Innovative advancements in techniques, pre-procedural optimum medical therapy (OMT), intraoperative neuro-monitoring, and multidisciplinary post procedural care are the few strategies in early detection and reduce stroke risk. Despite several innovations and strategies, it is evident that there is not enough data available to make concrete conclusions related to stroke risk after coronary revascularization, which warrants further investigation.

Perioperative pharmacotherapy to prevent cardiac complications in patients undergoing noncardiac surgery

Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complications after noncardiac surgery include myocardial ischemia, congestive heart failure, arrhythmias, and cardiac arrest. Along with surgical risk assessment, perioperative medical optimization can reduce the rates and clinical impact of these complications.Areas Covered: In this review, the authors discuss the pharmacological basis, existing evidence, and professional society recommendations for drug management in preventing cardiovascular complications in patients undergoing noncardiac surgery.Expert opinion: Perioperative management of cardiovascular disease is an increasingly important and growing area of clinical practice. Societal guidelines regarding the use of most routine cardiovascular medications are based on a number of large clinical studies and provide a basic foundation to guide management. However, the heterogeneous nature of patients, as well as surgeries, makes it practically impossible to devise a 'one size fits all' recommendation in this setting. Thus, the importance of a more individualized approach to perioperative risk stratification and management is being increasingly recognized. The underlying comorbidities and cardiac profile as well as the risk of cardiac complications associated with the planned surgery must be factored in to understand the nuance of the management strategies.

Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience

Objective  The aim of the study is to describe the real-world use of the P2Y ₁₂ inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT).

Materials and Methods  We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used.

Results  Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was <2 g/dL; nine patients received blood transfusions consistent with the type of surgery, but no life-threatening or fatal bleeding occurred.

Conclusion  Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.

Use of Cangrelor in Cervical and Intracranial Stenting for the Treatment of Acute Ischemic Stroke: A "Real Life" Single-Center Experience

BACKGROUND AND PURPOSE

In cases of large-vessel-occlusion strokes due to an underlying tandem internal carotid artery occlusion or intracranial atherosclerotic disease, concomitant stent placement may be needed. Immediate platelet inhibition is necessary, but to date, a standardized approach for antiplatelet inhibition in acute settings is still missing. Here we report our single-center experience about the safety and efficacy of periprocedural administration of cangrelor in patients with acute ischemic stroke due to intracranial or cervical artery occlusion undergoing stent placement.

MATERIALS AND METHODS

We retrospectively evaluated all cases of acute ischemic stroke that needed acute stent implantation and were treated with periprocedural administration of cangrelor between January 2019 and April 2020 at our institution. All patients who needed either extracranial or intracranial artery stent placement (in either the anterior or posterior circulation) were included.

RESULTS

We evaluated 38 patients in whom cangrelor was administered IV periprocedurally. Their mean age was 64 years (range, 26-85 years), with 25/38 male subjects and 13/38 female patients. In 26 patients (68.4%), a tandem occlusion was present and was treated with carotid artery stent placement, while 12 patients (31.6%) required an intracranial stent implantation. In 4 subjects (10.5%), an intracerebral hemorrhage occurred after the procedure. All patients in the series were alive 1 week after the procedure.

CONCLUSIONS

Although larger, multicentric randomized studies are strongly warranted, our results support the hypothesis of a possible role of cangrelor as a valuable therapeutic option in the management of platelet inhibition in acute ischemic stroke procedures after intra- or extracranial stent placement.

Cangrelor in clinical use

Inadequate antiplatelet effects can result in substantial morbidity and mortality in patients with acute coronary syndrome and percutaneous coronary intervention (PCI). Cangrelor is a rapid onset and potent intravenous P2Y12 inhibitor that has been shown in large randomized controlled trials to reduce periprocedural complications for PCI compared with clopidogrel, the most commonly used P2Y12 inhibitor. Cangrelor should be considered in the setting of PCI to reduce the risk of periprocedural complications such as myocardial infarction, repeat coronary revascularization and stent thrombosis in patients not yet treated with another P2Y12 inhibitor or glycoprotein IIb/IIIa inhibitor. In this review, the importance of adequate P2Y12 inhibition, cangrelor's pharmacology and clinical profiles, and future directions for the cangrelor are discussed.