Optimal platelet inhibition with cangrelor in comatose survivors of out-of-hospital cardiac arrest undergoing primary percutaneous coronary intervention

Fiore, Mathieu; Gerbaud, Édouard; Coste, Pierre; Cetran, Laura; Marchand, Hugo; Séguy, B

doi:10.1016/j.resuscitation.2018.06.032

Cited by 12 publications

(8 citation statements)

References 5 publications

(5 reference statements)

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“…The rapid onset and offset of cangrelor make it particularly attractive in patients at a high risk of both thrombotic and hemorrhagic complications. Indeed, in our cohort, 36% needed cangrelor transient discontinuation for up to 12 h. In the context of CS/CA patients undergoing PCI and receiving VA-ECMO, oral P2Y 12 inhibitors bioavailability is often unpredictable or inadequate as a result of longer metabolism, hypothermia, mechanical ventilation and use of concomitant drugs, 3 and cangrelor offers a more predictable pharmacokinetics 4 and does not require dose adjustment in case of renal or hepatic dysfunction. 5 A recent study on patients on VA-ECMO for CS after PCI and treated with aspirin, cangrelor and heparin found, however, a very high rate (>75%) of bleeding complications.…”

Section: Discussionmentioning

confidence: 82%

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

et al. 2022

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VA-ECMO is commonly used for patients in cardiogenic shock (CS) or refractory cardiac arrest (CA) undergoing PCI for ACS. In this setting at high risk of both thrombotic and hemorrhagic complications, optimal anti-thrombotic therapy remains ill-defined. We hypothesized that an anti-thrombotic therapy comprising a parenteral anticoagulant (bivalirudin) and a parenteral anti-platelet agent (cangrelor) may prove safe and effective in this scenario. From November 2019 to December 2021, 14 patients received at least one dose of cangrelor (starting dose: 0.125 μg/kg/min) plus bivalirudin, without background aspirin, in the context of PCI and VA-ECMO for ACS-related CS/CA, and were included in this study. Efficacy endpoint was occurrence of thrombotic events and safety endpoint was major bleeding occurrence. Median age was 58 years. The majority (64%) presented with refractory CA. A thrombotic event occurred in 14%, while major bleeding occurred in 21% patients. One patient experienced arterial thrombosis after VA-ECMO arterial cannula removal, another experienced ischemic cerebellar stroke without functional sequelae. Bleeding events were: 29% BARC 3a, 14% BARC 3b, and 7% BARC 5b. Overall in-hospital mortality was 50%. Cangrelor was continued for 5 (4–10) days; temporary discontinuation was necessary in 36%, either for VA-ECMO cannula removal or for bleeding events. A low dose of cangrelor, associated with standard-intensity anticoagulation with bivalirudin was a feasible anti-thrombotic strategy in patients undergoing PCI during VA-ECMO support for ACS-related CS/CA. Bleeding events rates outweighed thrombotic events rates in this critically-ill population, although the observed rates were lowest among available studies.

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Section: Discussionmentioning

confidence: 82%

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

et al. 2022

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“…In a small case series of 12 patients undergoing primary PCI for AMICS, there was no nonresponder to cangrelor, consistent with its mechanism of action which does not require absorption and bioactivation. In a small single‐center observational study of 22 patients presenting with out‐of‐hospital cardiac arrest, residual platelet activity was higher during the first 4 hr when ticagrelor was used alone compared with the combination of ticagrelor and cangrelor, and no patient experienced major bleeding . These findings were mirrored in a matched cohort of patients receiving therapeutic hypothermia treated with cangrelor ( n = 25) or oral P2Y12 inhibitors ( n = 17) that showed better platelet inhibition with cangrelor without raising bleeding safety concerns .…”

Section: Adjunctive Antithrombotic Pharmacotherapymentioning

confidence: 90%

Technical consideration in acute myocardial infarction with cardiogenic shock: A review of antithrombotic and PCI therapies

Marquis‐Gravel

Zeitouni

Kochar

et al. 2019

Cathet Cardio Intervent

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In this review, we report a contemporary appraisal of the available evidence focusing on adjunctive antithrombotic therapy and technical aspects of percutaneous coronary interventions (PCI) in patients with acute myocardial infarction and cardiogenic shock (AMICS). Only few randomized trials have been conducted to evaluate the optimal arterial access choice, antithrombotic therapy, stent type, or the role of aspiration thrombectomy in this population. Observational data suggest that a transradial approach should be preferred for experienced operators, although knowledge and experience of transfemoral access is required to place any mechanical support device.In the absence of high-quality evidence to guide choice of the adjunctive antithrombotic drugs to support PCI in patients with AMICS, knowledge of the altered pharmacokinetics and pharmacodynamics in shock is required to inform decisions.Drug-eluting stents should be favored over bare-metal stents, and routine thrombectomy is not encouraged. Owing to the challenges inherent to the conduct of randomized trials in this acutely ill patient population, concerted multicenter, and international efforts are paramount to orchestrate the development of high-quality evidence to guide clinical practice.anticoagulant, antiplatelet, aspiration thrombectomy, cardiogenic shock, percutaneous coronary intervention, radial access

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“…As many cardiogenic shock patients arrive to the cath lab in a comatose condition hereby making oral administration impossible, this treatment option seems reasonable [52]. Another possibility is intravenous antiplatelet therapy with cangrelor, which have shown predominantly promising results in the very few existing small-scale studies comparing different antiplatelet strategies [53,54]. However, long-term treatment with cangrelor (i.e.…”

Section: Antithrombotic Treatmentmentioning

confidence: 99%

Interventional treatment of acute myocardial infarction-related cardiogenic shock

Josiassen

Møller

Holmvang

et al. 2021

Current Opinion in Critical Care

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Purpose of reviewAcute revascularization is with some evidence the only intervention proven to improve the prognosis in myocardial infarction-related cardiogenic shock but several interventions are continuously being investigated in order to increase survival among these patients. In this review, several aspects related to the interventional treatment of cardiogenic shock are discussed chronologically from symptom debut to leaving the cardiac catheterization laboratory.Recent findingsIn the randomized CULPRIT-SHOCK trial, a culprit-only revascularization strategy was reported superior to immediate complete revascularization among patients with multivessel disease. Recent large-scale observational data underline the marked prognostic importance of time from medical contact to revascularization in acute myocardial infarction-related cardiogenic shock. Moreover, studies suggest a potential beneficial effect of a transradial vascular access as well as early initialization of mechanical circulatory support in carefully selected patients. This, however, needs further validation.SummaryAcute revascularization remains a crucial part of the initial management of acute myocardial infarction-related cardiogenic shock. Among cardiogenic shock patients presenting with multivessel disease, a culprit-only approach should be the routine strategy. Time to revascularization plays a crucial role in the setting of cardiogenic shock, why prehospital optimization and triaging may be the most important factors in order to improve prognosis in AMI-related cardiogenic shock.

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Optimal platelet inhibition with cangrelor in comatose survivors of out-of-hospital cardiac arrest undergoing primary percutaneous coronary intervention

Cited by 12 publications

References 5 publications

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

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

Technical consideration in acute myocardial infarction with cardiogenic shock: A review of antithrombotic and PCI therapies

Interventional treatment of acute myocardial infarction-related cardiogenic shock

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