Oral P2Y₁₂ inhibitors only versus cangrelor in critically ill patients requiring percutaneous coronary interventions supported by microaxial flow pumps

Oral P2Y₁₂ inhibitors (P2Y₁₂i) may have reduced efficacy in critically ill patients undergoing Impella-supported PCI. The intravenous P2Y₁₂i cangrelor offers rapid and reversible platelet inhibition, but its role in this setting remains unclear.

Comparison of outcomes in patients undergoing Impella-supported PCI receiving oral P2Y₁₂i only versus loading with cangrelor.

We analyzed consecutive patients managed at a Swiss tertiary cardiology facility who underwent Impella-supported PCI. Patients received either (1) oral P2Y₁₂i or (2) cangrelor followed by oral P2Y₁₂i. Periprocedural major bleeding (BARC ≥ 3) within 48 h, in-hospital major adverse cardiovascular events (MACE) and 6-month MACE were analyzed.

Among 295 patients, 201 received oral P2Y₁₂i and 94 received cangrelor. Patients in the oral P2Y₁₂i group were less likely to present with STEMI (55.7% versus 67.0%) or cardiogenic shock (55.2% versus 72.3%), whereas high-risk protected PCI was more frequent (17.9% versus 6.4%) compared to cangrelor group. No significant differences were observed in major bleeding, in-hospital MACE and 6-month MACE. Major bleeding was numerically lower in the oral P2Y₁₂i group (26.4% versus 33.0%, p = 0.2). Early stent thrombosis rates were relatively low and not significantly different (1.0% versus 2.1%, p = 0.6). Presentation with cardiogenic shock was associated with a higher risk for post-PCI major bleeding (OR 7.09, 95%CI 2.97-18.49) and 6-month MACE (HR 2.01, 95% CI 1.01-3.97).

In Impella-supported PCI, cangrelor was associated with no statistically significant differences in outcomes compared to oral P2Y₁₂i, with consistent results after adjustment. Given the observational design, these findings require confirmation in randomized trials.