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Effect of Platelet Inhibition With Cangrelor During PCI on Ischemic Events
Study Questions:
What is the effect of cangrelor on ischemic complications of percutaneous coronary intervention (PCI)?
Methods:
In CHAMPION PHOENIX (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), a double-blind, placebo-controlled trial, the authors randomly assigned 11,145 patients who were undergoing either urgent or elective PCI and were receiving guideline-recommended therapy to receive a bolus and infusion of cangrelor, or to receive a loading dose of 600 mg or 300 mg of clopidogrel. The primary efficacy endpoint was a composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours after randomization; the key secondary endpoint was stent thrombosis at 48 hours. The primary safety endpoint was severe bleeding at 48 hours.
Results:
The rate of the primary efficacy endpoint was 4.7% in the cangrelor group and 5.9% in the clopidogrel group (adjusted odds ratio with cangrelor, 0.78; 95% confidence interval [CI], 0.66-0.93; p = 0.005). The rate of the primary safety endpoint was 0.16% in the cangrelor group and 0.11% in the clopidogrel group (odds ratio, 1.50; 95% CI, 0.53-4.22; p = 0.44). Stent thrombosis developed in 0.8% of the patients in the cangrelor group and in 1.4% in the clopidogrel group (odds ratio, 0.62; 95% CI, 0.43-0.90; p = 0.01). The rates of adverse events related to the study treatment were low in both groups, although transient dyspnea occurred significantly more frequently with cangrelor than with clopidogrel (1.2% vs. 0.3%). The benefit from cangrelor with respect to the primary endpoint was consistent across multiple prespecified subgroups.
Conclusions:
The authors concluded that cangrelor significantly reduced the rate of ischemic events, including stent thrombosis, during PCI, with no significant increase in severe bleeding.
Perspective:
This study reported that, as compared with clopidogrel, intravenous adenosine diphosphate (ADP) receptor blockade with cangrelor significantly reduced the rate of periprocedural complications of PCI, including stent thrombosis. A reduction in the rate of acute periprocedural myocardial infarction accounted for most of the benefit, and this benefit was not accompanied by a significant increase in severe bleeding or in the need for transfusions. More sensitive measures, however, did show an increase in bleeding with cangrelor. Future studies are needed to determine whether cangrelor reduces ischemic endpoints compared to more potent P2Y12-receptor inhibitors (i.e., prasugrel or ticagrelor). Cangrelor may be particularly useful in clinical situations in which ADP-receptor blockade is needed, but a short-acting intravenous agent would be preferred, for example, in patients waiting to undergo open-heart surgery.
Keywords: Platelet Aggregation Inhibitors, Percutaneous Coronary Intervention
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