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Downstream cangrelor versus upstream ticagrelor in patients with ST-segment elevation myocardial infarction: A
Antonio Greco1, Lorenzo Scalia2, Claudio Laudani1
1Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy.
Insights
Downstream cangrelor and upstream ticagrelor showed similar in-hospital safety and efficacy in ST-elevation myocardial infarction patients undergoing percutaneous coronary intervention. This study compared these P2Y12 inhibitors in STEMI patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- P2Y12 inhibitors are crucial for ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI).
- Intravenous cangrelor offers an alternative when oral P2Y12 inhibitor absorption is compromised.
- This study evaluates downstream cangrelor versus upstream ticagrelor in STEMI patients.
Purpose of the Study:
- To compare the efficacy and safety of downstream cangrelor versus upstream ticagrelor in STEMI patients undergoing primary PCI.
- To assess in-hospital major adverse cardiovascular events (MACE) and bleeding complications.
- To identify predictors of MACE in this patient population.
Main Methods:
- Prospective registry study including 761 STEMI patients undergoing PCI (October 2019 - June 2023).
- Comparison between downstream cangrelor (n=383) and upstream ticagrelor (n=378) groups.
- Propensity-matched analysis to evaluate primary (MACE) and secondary outcomes (death, MI, stent thrombosis, revascularization, bleeding).
Main Results:
- No significant difference in MACE between downstream cangrelor and upstream ticagrelor groups in the matched cohort (OR 1.30; 95% CI 0.79-2.17).
- Similar rates of all-cause death, myocardial infarction, stent thrombosis, repeat revascularization, and major bleeding were observed.
- Cardiogenic shock and glycoprotein IIb/IIIa inhibitor use predicted MACE; radial access was inversely associated.
Conclusions:
- Downstream cangrelor and upstream ticagrelor demonstrate comparable in-hospital safety and efficacy in P2Y12-naïve STEMI patients undergoing primary PCI.
- Neither strategy showed a significant difference in ischemic or bleeding events.
- Clinical factors like cardiogenic shock and access site influence outcomes.
Background:
Pretreatment with a P2Y12 inhibitor may be considered in patients with ST-segment elevation myocardial infarction (STEMI) referred to percutaneous coronary intervention (PCI). Intravenous cangrelor is an alternative in this setting, where oral absorption can be hindered. The aim of this study was to compare cangrelor administered after coronary angiography (i.e., "downstream") and ticagrelor pretreatment (i.e., "upstream").
Methods:
STEMI patients undergoing PCI from October 2019 to June 2023 were included. The primary outcome was the composite of in-hospital major adverse cardiovascular events (MACE). Secondary outcomes included individual components of the primary outcome and in-hospital major bleeding. Univariable and multivariable regression analyses were performed in unmatched and propensity-matched cohorts.
Results:
Of 6086 patients enrolled in the prospective CAST registry, 761 were included: 383 (50.3 %) received downstream cangrelor and 378 (49.7 %) upstream ticagrelor. In the matched population, no between-group differences were observed in MACE (odds ratio [OR] 1.30; 95 % confidence interval [CI] 0.79-2.17; P 0.308), all-cause death (OR 1.91; 95 % CI 0.87-4.54; P 0.124), myocardial infarction (OR 2.64; 95 % CI 0.76-12.14; P 0.154), stent thrombosis (OR 0.38; 95 % CI 0.06-1.80; P 0.255), unplanned repeat revascularization (OR 1.22; 95 % CI 0.32-4.98; P 0.766) and major bleeding (OR 0.98; 95 % CI 0.50-1.93; P 0.955). Cardiogenic shock and bailout administration of glycoprotein IIb/IIIa inhibitors were independent predictors of MACE, while radial access showed an inverse association with the primary outc.
Conclusions:
In P2Y12-naïve STEMI patients undergoing primary PCI, no significant differences were noted in the risk of in-hospital ischemic and bleeding events between downstream cangrelor and upstream ticagrelor.
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