Prehospital ticagrelor in ST-segment elevation myocardial infarction
Gilles Montalescot1, Arnoud W van 't Hof, Frédéric Lapostolle
1The authors' affiliations are listed in the Appendix.
Insights
Prehospital ticagrelor for ST-segment elevation myocardial infarction (STEMI) is safe but does not improve early reperfusion. This study found no significant difference in primary outcomes between prehospital and in-hospital administration.
Area of Science:
- Cardiology
- Clinical Trials
- Pharmacology
Background:
- Ticagrelor, a P2Y12 inhibitor, reduces adverse cardiovascular events in STEMI patients.
- The benefit of prehospital ticagrelor administration on coronary reperfusion and outcomes is not established.
Purpose of the Study:
- To evaluate the efficacy and safety of prehospital versus in-hospital ticagrelor administration in STEMI patients.
- To assess the impact on ST-segment elevation resolution and coronary artery flow before percutaneous coronary intervention (PCI).
Main Methods:
- International, randomized, double-blind study of 1862 STEMI patients.
- Compared prehospital (ambulance) versus in-hospital ticagrelor administration.
- Coprimary end points: ST-segment elevation resolution and Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 before PCI.
Main Results:
- No significant difference in coprimary end points between prehospital and in-hospital groups.
- Major adverse cardiovascular events rates were similar.
- Definite stent thrombosis rates were lower in the prehospital group at 30 days (0.2% vs 1.2%).
- Major bleeding events were low and comparable between groups.
Conclusions:
- Prehospital ticagrelor administration in acute STEMI is safe.
- It did not improve pre-PCI coronary reperfusion.
- Further research may explore its role in specific patient subgroups.
Background:
The direct-acting platelet P2Y12 receptor antagonist ticagrelor can reduce the incidence of major adverse cardiovascular events when administered at hospital admission to patients with ST-segment elevation myocardial infarction (STEMI). Whether prehospital administration of ticagrelor can improve coronary reperfusion and the clinical outcome is unknown.
Methods:
We conducted an international, multicenter, randomized, double-blind study involving 1862 patients with ongoing STEMI of less than 6 hours' duration, comparing prehospital (in the ambulance) versus in-hospital (in the catheterization laboratory) treatment with ticagrelor. The coprimary end points were the proportion of patients who did not have a 70% or greater resolution of ST-segment elevation before percutaneous coronary intervention (PCI) and the proportion of patients who did not have Thrombolysis in Myocardial Infarction flow grade 3 in the infarct-related artery at initial angiography. Secondary end points included the rates of major adverse cardiovascular events and definite stent thrombosis at 30 days.
Results:
The median time from randomization to angiography was 48 minutes, and the median time difference between the two treatment strategies was 31 minutes. The two coprimary end points did not differ significantly between the prehospital and in-hospital groups. The absence of ST-segment elevation resolution of 70% or greater after PCI (a secondary end point) was reported for 42.5% and 47.5% of the patients, respectively. The rates of major adverse cardiovascular events did not differ significantly between the two study groups. The rates of definite stent thrombosis were lower in the prehospital group than in the in-hospital group (0% vs. 0.8% in the first 24 hours; 0.2% vs. 1.2% at 30 days). Rates of major bleeding events were low and virtually identical in the two groups, regardless of the bleeding definition used.
Conclusions:
Prehospital administration of ticagrelor in patients with acute STEMI appeared to be safe but did not improve pre-PCI coronary reperfusion. (Funded by AstraZeneca; ATLANTIC ClinicalTrials.gov number, NCT01347580.).
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