Clinical Use of Cangrelor After Percutaneous Coronary Intervention in Patients Requiring Mechanical Circulatory Support

Abstract

Background: Patients with cardiogenic shock after percutaneous coronary intervention (PCI) may require mechanical circulatory support (MCS). The combination of dual antiplatelet therapy with cangrelor and continuous anticoagulation required for MCS may increase the risk of bleeding. Objective: The objective of the study is to describe the complications and outcomes of patients who received cangrelor during MCS following PCI. Methods: This is a single-center, retrospective, observational case series of 17 patients who received cangrelor while on MCS from June 2017 to September 2019. Results: In a case series of 17 patients, 8 patients (47%) were supported with an Impella device and 4 patients (24%) with venoarterial (VA) extracorporeal membrane oxygenation (ECMO); 5 required (29%) concomitant VA ECMO and Impella support in the setting of cardiogenic shock. All patients received triple antithrombotic therapy with aspirin, heparin, and cangrelor. Cangrelor was commonly initiated at a median dose of 0.75 (range 0.5-4) µg/kg/min. Cangrelor dose adjustments included changes in increments up to 0.25 µg/kg/min with review of P2Y12 levels. A total of 10 patients (59%) experienced a bleeding event, most commonly located at the peripheral cannulation site (40%) and in the gastrointestinal tract (30%). Seven (70%) and 3 (30%) of the bleeding complications were classified as major and minor, respectively. No patient developed in-stent thrombosis during the hospitalization; 14 (82%) patients survived their MCS course. Conclusion and Relevance: This case series suggests that cangrelor doses less than 0.75 µg/kg/min may be beneficial. Larger studies should evaluate alternative dosing regimens.

Antithrombotic management for Impella® temporary ventricular assist devices: An analysis of an academic health-system experience

“…In addition, further studies should evaluate the optimal DAPT strategy, including either omitting aspirin, using clopidogrel only, or administering reduced dose cangrelor while the Impella ® device is in place, 17 to mitigate the risk of bleeding associated with triple antithrombotic therapy.…”

“…It has been suggested that a cangrelor dose <0.75 µg/kg/min may be beneficial in reducing the risk of bleeding in patients receiving on Impella ® or ECMO. 17 The preferred antiplatelet agent and optimum dosing strategies remains to be determined. There are several limitations to our study, including its observational, retrospective design.…”

“…Future studies should explore utilizing the heparin anti-Xa assay to monitor Impella ® devices, to further determine if targeting a prophylactic degree of anticoagulation with an upper limit anti-Xa goal <0.4 correlates with decreased bleeding, without an increase in thromboembolic events. In addition, further studies should evaluate the optimal DAPT strategy, including either omitting aspirin, using clopidogrel only, or administering reduced dose cangrelor while the Impella ® device is in place, 17 to mitigate the risk of bleeding associated with triple antithrombotic therapy.…”

Anti-thrombotic Therapy with Cangrelor and Bivalirudin in Venoarterial Extracorporeal Membrane Oxygenation Patients Undergoing Percutaneous Coronary Intervention: A Single-Center Experience

“…Finally, our BARC 3-5 bleeding event rates (50%) were the lowest among reports on cangrelor use in VA-ECMO patients, that range between 67-100% (Figure 1B). 2,15,18 Specifically, a cohort comprising CS shocks patient on VA-ECMO who received PCI found a 77% rate of BARC 3-5 bleeding; in this cohort cangrelor was chiefly combined with aspirin (in 85%) and heparin (in 92%). 2 Katz et al 15 found a 67% rate of BARC 3-5 bleeding in a cohort of PCI patients with CS on VA-ECMO who received aspirin, heparin, and cangrelor titrated by platelet function test.…”

“…2,15,18 Specifically, a cohort comprising CS shocks patient on VA-ECMO who received PCI found a 77% rate of BARC 3-5 bleeding; in this cohort cangrelor was chiefly combined with aspirin (in 85%) and heparin (in 92%). 2 Katz et al 15 found a 67% rate of BARC 3-5 bleeding in a cohort of PCI patients with CS on VA-ECMO who received aspirin, heparin, and cangrelor titrated by platelet function test. Finally, in a cohort of patients receving cangrelor as bridging to surgery or if oral medications were contraindicated, BARC 3-5 bleeding rates occurred in 100% in the VA-ECMO subgroup: no other details on antithrombotic therapy in this subgroup are available.…”