Cangrelor: a novel intravenous antiplatelet agent with a questionable future

Area of Science:

• Cardiovascular medicine
• Pharmacology
• Interventional cardiology

Background:

• Current percutaneous coronary intervention (PCI) guidelines mandate P2Y12 inhibitors with aspirin and anticoagulants.
• Oral P2Y12 inhibitors present challenges including drug interactions, variable absorption, and delayed action, particularly for patients needing coronary artery bypass graft (CABG) surgery.

Purpose of the Study:

• To evaluate cangrelor, a novel intravenous P2Y12 inhibitor, as an alternative to oral agents for PCI and as bridging therapy for CABG surgery.
• To assess cangrelor's efficacy and safety in preventing thrombotic events and managing platelet inhibition.

Main Methods:

• The Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition (CHAMPION) trials compared cangrelor with oral clopidogrel in PCI patients.
• The BRIDGE study evaluated cangrelor as a substitute for oral P2Y12 inhibitors in patients awaiting CABG surgery.

Main Results:

• CHAMPION trials yielded conflicting results, but suggested lower stent thrombosis and composite cardiovascular events with cangrelor versus clopidogrel, with similar bleeding rates.
• The BRIDGE study demonstrated cangrelor's ability to maintain preoperative platelet inhibition and allow rapid return to baseline function post-infusion.

Conclusions:

• Despite promising data from CHAMPION and BRIDGE studies, the FDA denied approval for cangrelor's PCI and bridging indications due to concerns regarding risk-benefit ratio and data sufficiency.
• The future of cangrelor as a novel intravenous antiplatelet agent remains uncertain pending further investigation and data submission.