"Tailored" antiplatelet bridging therapy with cangrelor: moving toward personalized medicine

Area of Science:

• Cardiology
• Pharmacology
• Perioperative Medicine

Background:

• Patients on dual antiplatelet therapy (DAPT) undergoing surgery face high risks of perioperative cardiac ischemic events, including stent thrombosis, due to surgery's prothrombotic nature and DAPT withdrawal to prevent bleeding.
• Cangrelor, an intravenous P2Y₁₂ receptor antagonist, has been used as a bridging therapy to surgery after oral P2Y₁₂ inhibitor discontinuation, with its off-label use extended to non-cardiac surgeries.
• Despite standardized cangrelor bridging protocols, a residual risk of adverse outcomes, primarily bleeding events, persists during the perioperative phase.

Purpose of the Study:

• To propose a tailored clinical decision-making algorithm for managing patients on DAPT undergoing surgery, inspired by personalized medicine principles.
• To address complex clinical scenarios where standardized bridging protocols may not be optimal.
• To optimize patient outcomes and healthcare costs by moving beyond average pharmacodynamic data of oral P2Y₁₂ inhibitors.

Main Methods:

• Review of existing literature and consensus statements on perioperative bridging therapy with cangrelor.
• Development of a personalized management strategy based on serial platelet reactivity measurements.
• Incorporation of careful assessment of individual ischemic and bleeding risks into clinical decision-making.

Main Results:

• Standardized cangrelor bridging protocols, while beneficial, leave a residual risk of perioperative adverse events, particularly bleeding.
• Personalized management, guided by platelet reactivity and risk assessment, holds potential to optimize outcomes and reduce costs.
• This approach aims to provide a more individualized strategy compared to protocols based on average pharmacodynamic data.

Conclusions:

• A personalized, risk-stratified approach to perioperative management of patients on DAPT is warranted.
• Serial platelet reactivity measurements and tailored risk assessment can potentially improve upon standardized cangrelor bridging protocols.
• The proposed algorithm aims to enhance clinical decision-making in complex perioperative scenarios, optimizing patient safety and treatment efficacy.