Timing, indications and transition patterns associated with cangrelor use in patients undergoing PCI

Optimal antiplatelet therapy is crucial in percutaneous coronary intervention (PCI) to balance thrombotic and bleeding risk. Cangrelor, a rapid-acting intravenous P2Y12 inhibitor, is particularly effective in high-risk PCI scenarios, including acute coronary syndrome (ACS) or patients unable to take oral medications. The SMILE study evaluated real-world timing, indications, and outcomes of cangrelor use, along with transition to oral P2Y12 inhibitors, in high-risk patients undergoing PCI. A retrospective analysis of Mount Sinai PCI registry was conducted, examining consecutive patients receiving cangrelor from January 2018 to March 2024. Transition to oral P2Y12 inhibitors (ticagrelor, clopidogrel, or prasugrel) followed institutional protocols based on guidelines and expert consensus. The primary endpoint was in-hospital major adverse cardiac and cerebrovascular events (MACCE), including myocardial infarction, stroke, and all-cause death. Among 493 patients, 78.7% presented with ACS (29.6% STEMI; 14.8% cardiogenic shock) and 79.3% underwent complex PCI. Of these, 80.5% were subsequently transitioned to ticagrelor (N=397) and 19.5% to a thienopyridine (clopidogrel N=85, prasugrel N=11). MACCE incidence was 12.6%, while bleeding occurred in 4.3%. A lower risk of MACCE was associated with transition to ticagrelor (9.8% vs. 24.0%; adjusted OR 0.35, 95%CI 0.20-0.62, p < 0.001) and adherence to protocol for transition to oral P2Y12 inhibitors (10.9% vs. 19.4%; adjusted OR 0.51, 95%CI 0.28-0.94). Extended low-dose cangrelor infusion was well-tolerated in critically ill patients requiring prolonged parenteral antiplatelet therapy. Overall, the SMILE study demonstrated that adherence to standardized transition protocols enhances clinical outcomes in high-risk PCI patients receiving cangrelor, particularly when transitioned to ticagrelor. Further research is needed to validate these results across diverse populations and clinical settings.