Comparison of clinical outcomes with cangrelor plus aspirin versus oral dual antiplatelet therapy in patients supported with venoarterial extracorporeal membrane oxygenation

Abstract

BackgroundPatients with refractory cardiogenic shock from an acute myocardial infarction may receive percutaneous coronary intervention (PCI) and require the use of venoarterial extracorporeal membrane oxygenation (VA–ECMO). The purpose of this study was to compare bleeding and thrombotic events in patients treated with cangrelor plus aspirin versus oral dual antiplatelet therapy (DAPT) while supported with VA–ECMO.MethodsWe conducted a retrospective review of patients who received PCI, were supported with VA–ECMO, and were treated with either cangrelor plus aspirin or oral DAPT from February 2016 through May 2021 at Allegheny General Hospital. The primary objective was the incidence of major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or greater. The incidence of thrombotic events was a secondary objective.ResultsThirty‐seven patients were included, 19 in the cangrelor plus aspirin group, and 18 in the oral DAPT group. All the patients in the cangrelor group received a dose of 0.75 mcg/kg/min. Major bleeding occurred in 7 patients (36.8%) in the cangrelor group compared to 7 patients (38.9%) in the oral DAPT group (p = 0.90). No patient developed stent thrombosis. Two patients (10.5%) in the cangrelor group had a thrombotic event versus 3 patients (16.7%) in the oral DAPT group (p = 0.66).ConclusionsBleeding and thrombotic events were comparable between patients receiving cangrelor plus aspirin versus oral DAPT while on VA–ECMO.

Platelet Function Testing to Guide Cangrelor Dosing in Patients with Temporary Mechanical Circulatory Support or as a Bridge to Procedure

“…Similar to our study, previous studies in patients with MCS on cangrelor have demonstrated higher bleeding events than thrombotic events with major bleeding occurring in 21–77% of patients and thrombotic events in 10–35% of patients. 4 – 6 , 12 Therefore, additional focus is needed to better reduce bleeding events while preventing thrombotic events. Utilizing PFT-guided cangrelor dosing in our study allowed for lower cangrelor dosing while maintaining adequate antiplatelet activity, which may reduce bleeding risk.…”

“…Several previous studies in patients supported with VA-ECMO or as bridging therapy used empiric cangrelor dosing of 0.75 mcg/kg/min based on similar dosing used in the BRIDGE trial. 4 , 5 , 7 – 11 Other studies allowed for lower cangrelor doses between 0.5 and 0.75 mcg/kg/min 12 , 13 with PRU monitoring or empiric dosing as low as 0.125 mcg/kg/min in one study of patients supported on VA-ECMO. 6 In our study, we utilized an initial dose of 0.75 mcg/kg/min with subsequent dose adjustments based upon PRU values.…”

“…Previous studies have evaluated the off-label use of low dose cangrelor in patients requiring temporary mechanical circulatory support (MCS) or in bridging cases before surgery or a procedure. 4 – 14 Additionally, small case series have assessed using platelet function testing (PFT) with the VerifyNow P2Y12 assay to guide cangrelor dosing in bridging situations or in patients with temporary MCS; however, these previous studies lacked a standardized protocol for dose adjustments based upon P2Y12 reaction units (PRU) and utilized different goal values for PRU. 12 – 14 Therefore, additional studies are needed to better evaluate the clinical utility of PFT to guide cangrelor dosing.…”