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Cangrelor in STEMI as a bridge to CABG- a mini-case series
Bishesh Shrestha1, Daniel Katz1, John Kelley2
1Department of Cardiology, Bassett Medical Center, Cooperstown, NY, United States of America.
Insights
Cangrelor, an intravenous antiplatelet, allows timely coronary artery bypass grafting (CABG) in STEMI patients with multi-vessel disease. This avoids delays associated with oral agents, ensuring rapid treatment and recovery without bleeding complications.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Patients with ST-elevation myocardial infarction (STEMI) require dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist.
- Some STEMI patients have multi-vessel disease necessitating urgent coronary artery bypass grafting (CABG).
- Oral P2Y12 inhibitors have prolonged effects, potentially delaying necessary CABG surgery due to bleeding risks.
Purpose of the Study:
- To evaluate the safety and efficacy of cangrelor in STEMI patients requiring emergent CABG.
- To assess if cangrelor administration impacts the timing of CABG surgery.
Main Methods:
- Retrospective case series of three STEMI patients.
- Patients received intravenous cangrelor as part of DAPT prior to cardiac catheterization.
- Coronary angiography identified multi-vessel disease requiring CABG.
Main Results:
- All three patients underwent successful CABG within 24-48 hours of cangrelor initiation.
- Cangrelor infusion was discontinued approximately one hour before surgery.
- No significant bleeding complications were reported, and patients experienced rapid recovery.
Conclusions:
- Cangrelor is a viable P2Y12 inhibitor for STEMI patients who may require urgent CABG.
- Its short half-life and rapid reversibility facilitate timely surgical intervention without compromising patient safety.
Background:
Patients with STEMI receive dual antiplatelet therapy as soon as possible with aspirin and a P2Y12 receptor antagonist prior to PCI. A fraction of these patients may have multi-vessel disease needing emergent CABG surgery. The choice of a P2Y12 receptor antagonist plays a role in the timing of CABG surgery as it poses a bleeding risk until it is completely eliminated from the system. Oral P2Y12 receptor antagonists have a long duration of platelet inhibition which is difficult to reverse. Cangrelor is an intravenous P2Y12 receptor antagonist with a short half-life and rapid cessation of its effect after discontinuation.
Methods:
Three patients who presented to our emergency department with STEMI were started on cangrelor infusion prior to cardiac catheterization instead of other P2Y12 receptor antagonists like clopidogrel or ticagrelor. The study received ethical approval as it is part of the current standard of care for STEMI patients.
Results:
All three patients were found to have multi-vessel disease during coronary angiography requiring CABG surgery. As cangrelor was used in these patients they were able to have their surgery within 24-48 h. Intravenous cangrelor was stopped about an hour before surgery. No bleeding complications occurred and all three patients made a speedy recovery in the ICU.
Conclusion:
Cangrelor is a potent P2Y12 receptor antagonist which can be used in patients presenting with STEMI as one of the two anti-platelet agents along with aspirin without any dilemma that it would cause a delay in CABG surgery if the patients need one.
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