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Effect of Cangrelor on Infarct Size in STEMI Treated by PCI
Quick Takes
- The addition of cangrelor at the onset of reperfusion to STEMI patients pretreated with oral ticagrelor did not reduce acute MI size or prevent microvascular obstruction (MVO) when compared to placebo, despite achieving faster platelet inhibition during PCI by two-fold.
- Of importance, there was no effect of cangrelor on chronic MI size and LV remodeling parameters at 6 months compared to placebo.
- There is no added benefit for bridging with intravenous cangrelor during the PCI procedure in terms of reducing acute infarct size or preventing MVO.
Study Questions:
What is the impact of the administration of cangrelor at reperfusion on myocardial infarct (MI) size and microvascular obstruction (MVO) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI)?
Methods:
The PITRI (Platelet Inhibition to Target Reperfusion Injury) investigators conducted a phase 2, multicenter, randomized, double-blind, placebo-controlled clinical trial between November 2017–November 2021 in six cardiac centers in Singapore (NCT03102723). Patients were randomized to receive either cangrelor or placebo initiated prior to the PPCI procedure on top of oral ticagrelor. The key exclusion criteria included: presenting <6 hours of symptom onset, prior MI and stroke or transient ischemic attack, on concomitant oral anticoagulants, and a contraindication for cardiovascular magnetic resonance (CMR). The primary efficacy endpoint was acute MI size by CMR within the first week expressed as percentage of the left ventricle mass (%LV mass). MVO was identified as areas of dark core of hypoenhancement within areas of late gadolinium enhancement. The primary safety endpoint was Bleeding Academic Research Consortium (BARC)-defined major bleeding in the first 48 hours. Continuous variables were compared by Mann-Whitney U test [reported as median (1st quartile-3rd quartile)] and categorical variables were compared by Fisher’s exact test. A 2-sided p < 0.05 was considered statistically significant.
Results:
Of 209 recruited patients, 164 patients (78%) completed the acute CMR scan. There were no significant differences in acute MI size [placebo: 14.9 (7.3–22.6) %LV mass vs. cangrelor: 16.3 (9.9–24.4) %LV mass, p = 0.40] or the incidence [placebo: 48% vs. cangrelor: 47%, p = 0.99] and extent of MVO [placebo: 1.63 (0.60–4.65) %LV mass vs. cangrelor: 1.18 (0.53–3.37) %LV mass, p = 0.46] between placebo and cangrelor despite a two-fold decrease in platelet reactivity with cangrelor. There were no BARC-defined major bleeding events in either group in the first 48 hours.
Conclusions:
The authors report that cangrelor administered at the time of PPCI did not reduce acute MI size or prevent MVO in STEMI patients given oral ticagrelor.
Perspective:
This study reports that the addition of cangrelor at the onset of reperfusion to STEMI patients pretreated with oral ticagrelor did not reduce acute MI size or prevent MVO when compared to placebo, despite achieving faster platelet inhibition during PCI by approximately two-fold. Furthermore, of importance, there was no effect of cangrelor on chronic MI size and LV remodeling parameters at 6 months compared to placebo. These data suggest that there is currently no added benefit for bridging with intravenous cangrelor during the PCI procedure in terms of reducing acute infarct size or preventing MVO and, thus, does not appear justified.
Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS
Keywords: Acute Coronary Syndrome, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors
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