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Intravenous antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

A report from the INVEST-STEMI group

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Abstract

The use of intravenous antiplatelet therapy during primary percutaneous coronary intervention (PPCI) is not fully standardized. The aim is to evaluate the effectiveness and safety of periprocedural intravenous administration of cangrelor or tirofiban in a contemporary ST-segment elevation myocardial infarction (STEMI) population undergoing PPCI. This was a multicenter prospective cohort study including consecutive STEMI patients who received cangrelor or tirofiban during PPCI at seven Italian centers. The primary effectiveness measure was the angiographic evidence of thrombolysis in myocardial infarction (TIMI) flow < 3 after PPCI. The primary safety outcome was the in-hospital occurrence of BARC (Bleeding Academic Research Consortium) 2–5 bleedings. The study included 627 patients (median age 63 years, 79% males): 312 received cangrelor, 315 tirofiban. The percentage of history of bleeding, pulmonary edema and cardiogenic shock at admission was comparable between groups. Patients receiving cangrelor had lower ischemia time compared to tirofiban. TIMI flow before PPCI and TIMI thrombus grade were comparable between groups. At propensity score-weighted regression analysis, the risk of TIMI flow < 3 was significantly lower in patients treated with cangrelor compared to tirofiban (adjusted OR: 0.40; 95% CI: 0.30–0.53). The risk of BARC 2–5 bleeding was comparable between groups (adjusted OR:1.35; 95% CI: 0.92–1.98). These results were consistent across multiple prespecified subgroups, including subjects stratified for different total ischemia time, with no statistical interaction. In this real-world multicenter STEMI population, the use of cangrelor was associated with improved myocardial perfusion assessed by coronary angiography after PPCI without increasing clinically-relevant bleedings compared to tirofiban.

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Data Availability

The datasets generated and/or analyzed during the current study may be available from the first author upon reasonable request.

References

  1. Franchi F, Rollini F, Angiolillo DJ (2017) Antithrombotic therapy for patients with STEMI undergoing primary PCI. Nat Rev Cardiol 14(6):361–379. https://doi.org/10.1038/nrcardio.2017.18

    Article  CAS  PubMed  Google Scholar 

  2. (1997) EUROASPIRE. A European Society of Cardiology survey of secondary prevention of coronary heart disease: principal results. EUROASPIRE Study Group. European Action on Secondary Prevention through Intervention to Reduce Events. Eur Heart J 18(10):1569–82. https://doi.org/10.1093/oxfordjournals.eurheartj.a015136

  3. Capodanno D, Alfonso F, Levine GN, Valgimigli M, Angiolillo DJ (2018) ACC/AHA versus ESC guidelines on dual antiplatelet therapy: JACC guideline comparison. J Am Coll Cardiol 72(23 Pt A):2915–31. https://doi.org/10.1016/j.jacc.2018.09.057

  4. Scudiero F, Canonico ME, Sanna GD et al (2023) Dual antiplatelet therapy with 3(rd) generation P2Y(12) inhibitors in STEMI patients: impact of body mass index on loading dose-response. Cardiovasc Drugs Ther 37(4):695–703. https://doi.org/10.1007/s10557-022-07322-2

    Article  CAS  PubMed  Google Scholar 

  5. Parodi G, Valenti R, Bellandi B et al (2013) Comparison of prasugrel and ticagrelor loading doses in ST-segment elevation myocardial infarction patients: RAPID (Rapid Activity of Platelet Inhibitor Drugs) primary PCI study. J Am Coll Cardiol 61(15):1601–1606. https://doi.org/10.1016/j.jacc.2013.01.024

    Article  CAS  PubMed  Google Scholar 

  6. De Luca L, Steg PG, Bhatt DL, Capodanno D, Angiolillo DJ (2021) Cangrelor: clinical data, contemporary use, and future perspectives. J Am Heart Assoc 10(13):e022125. https://doi.org/10.1161/jaha.121.022125

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Bhatt DL, Stone GW, Mahaffey KW et al (2013) Effect of platelet inhibition with cangrelor during PCI on ischemic events. N Engl J Med 368(14):1303–1313. https://doi.org/10.1056/NEJMoa1300815

    Article  CAS  PubMed  Google Scholar 

  8. Stone GW, Bertrand ME, Moses JW et al (2007) Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY timing trial. JAMA 297(6):591–602. https://doi.org/10.1001/jama.297.6.591

    Article  CAS  PubMed  Google Scholar 

  9. Giugliano RP, White JA, Bode C et al (2009) Early versus delayed, provisional eptifibatide in acute coronary syndromes. N Engl J Med 360(21):2176–2190. https://doi.org/10.1056/NEJMoa0901316

    Article  CAS  PubMed  Google Scholar 

  10. Valgimigli M, Bueno H, Byrne RA et al (2018) 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: the task force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 39(3):213–260. https://doi.org/10.1093/eurheartj/ehx419

    Article  PubMed  Google Scholar 

  11. Byrne RA, Rossello X, Coughlan JJ et al (2023) 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J Acute Cardiovasc Care. https://doi.org/10.1093/ehjacc/zuad107

  12. Ibanez B, James S, Agewall S et al (2018) 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 39(2):119–177. https://doi.org/10.1093/eurheartj/ehx393

    Article  PubMed  Google Scholar 

  13. Farooq V, van Klaveren D, Steyerberg EW et al (2013) Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet (London, England) 381(9867):639–650. https://doi.org/10.1016/s0140-6736(13)60108-7

    Article  PubMed  Google Scholar 

  14. (1985) The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. N Engl J Med 312(14):932–6. https://doi.org/10.1056/nejm198504043121437

  15. Gibson CM, de Lemos JA, Murphy SA et al (2001) Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction: a TIMI 14 substudy. Circulation 103(21):2550–2554. https://doi.org/10.1161/01.cir.103.21.2550

    Article  CAS  PubMed  Google Scholar 

  16. Poli A, Fetiveau R, Vandoni P et al (2002) Integrated analysis of myocardial blush and ST-segment elevation recovery after successful primary angioplasty: real-time grading of microvascular reperfusion and prediction of early and late recovery of left ventricular function. Circulation 106(3):313–318. https://doi.org/10.1161/01.cir.0000022691.71708.94

    Article  PubMed  Google Scholar 

  17. Baldi C, Polito MV, Citro R et al (2017) Prognostic value of clinical, echocardiographic and angiographic indicators in patients with large anterior ST-segment elevation myocardial infarction as a first acute coronary event. J Cardiovasc Med (Hagerstown) 18(12):946–953. https://doi.org/10.2459/jcm.0000000000000528

    Article  PubMed  Google Scholar 

  18. Mehran R, Rao SV, Bhatt DL et al (2011) Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 123(23):2736–2747. https://doi.org/10.1161/circulationaha.110.009449

    Article  PubMed  Google Scholar 

  19. Glynn RJ, Schneeweiss S, Stürmer T (2006) Indications for propensity scores and review of their use in pharmacoepidemiology. Basic Clin Pharmacol Toxicol 98(3):253–259. https://doi.org/10.1111/j.1742-7843.2006.pto_293.x

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Patrick AR, Schneeweiss S, Brookhart MA et al (2011) The implications of propensity score variable selection strategies in pharmacoepidemiology: an empirical illustration. Pharmacoepidemiol Drug Saf 20(6):551–559. https://doi.org/10.1002/pds.2098

    Article  PubMed  PubMed Central  Google Scholar 

  21. Sterne JA, White IR, Carlin JB et al (2009) Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ 338:b2393. https://doi.org/10.1136/bmj.b2393

    Article  PubMed  PubMed Central  Google Scholar 

  22. Grimfjärd P, Lagerqvist B, Erlinge D, Varenhorst C, James S (2019) Clinical use of cangrelor: nationwide experience from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Eur Heart J Cardiovasc Pharmacother 5(3):151–157. https://doi.org/10.1093/ehjcvp/pvz002

    Article  PubMed  Google Scholar 

  23. Franchi F, Rollini F, Rivas A et al (2019) Platelet inhibition with cangrelor and crushed ticagrelor in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Circulation 139(14):1661–1670. https://doi.org/10.1161/circulationaha.118.038317

    Article  CAS  PubMed  Google Scholar 

  24. Franchi F, Ortega-Paz L, Rollini F et al (2023) Cangrelor in patients with coronary artery disease pretreated with ticagrelor: the switching antiplatelet (SWAP)-5 study. JACC Cardiovasc Interv 16(1):36–46. https://doi.org/10.1016/j.jcin.2022.10.034

    Article  PubMed  Google Scholar 

  25. Zeymer U, Lober C, Richter S et al (2023) Cangrelor in patients with percutaneous coronary intervention for acute myocardial infarction after cardiac arrest and/or with cardiogenic shock. Eur Heart J Acute Cardiovasc Care 12(7):462–463. https://doi.org/10.1093/ehjacc/zuad041

    Article  PubMed  Google Scholar 

  26. Kordis P, Bozic Mijovski M, Berden J, Steblovnik K, Blinc A, Noc M (2023) Cangrelor for comatose survivors of out-of-hospital cardiac arrest undergoing percutaneous coronary intervention: the CANGRELOR-OHCA study. EuroIntervention 18(15):1269–1271. https://doi.org/10.4244/EIJ-D-22-00675

    Article  PubMed  PubMed Central  Google Scholar 

  27. Baldi C, Silverio A, Esposito L et al (2021) Clinical outcome of patients with ST-elevation myocardial infarction and angiographic evidence of coronary artery ectasia. Catheter Cardiovasc Interv 99(2):340–347. https://doi.org/10.1002/ccd.29738

  28. De Luca G, Silverio A, Verdoia M et al (2022) Angiographic and clinical outcome of SARS-CoV-2 positive patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: a collaborative, individual patient data meta-analysis of six registry-based studies. Eur J Intern Med 105:69–76. https://doi.org/10.1016/j.ejim.2022.08.021

    Article  PubMed  PubMed Central  Google Scholar 

  29. Gargiulo G, Esposito G, Avvedimento M et al (2020) Cangrelor, tirofiban, and chewed or standard prasugrel regimens in patients with ST-segment-elevation myocardial infarction: primary results of the FABOLUS-FASTER trial. Circulation 142(5):441–454. https://doi.org/10.1161/circulationaha.120.046928

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Angiolillo DJ, Bhatt DL, Stone GW (2021) Letter by Angiolillo et al regarding article, “Cangrelor, tirofiban, and chewed or standard prasugrel regimens in patients with ST-segment-elevation myocardial infarction: primary results of the FABOLUS FASTER trial.” Circulation 143(13):e795–e796. https://doi.org/10.1161/circulationaha.120.050205

    Article  PubMed  Google Scholar 

  31. Vaduganathan M, Harrington RA, Stone GW et al (2017) Evaluation of ischemic and bleeding risks associated with 2 parenteral antiplatelet strategies comparing cangrelor with glycoprotein IIb/IIIa inhibitors: an exploratory analysis from the CHAMPION Trials. JAMA Cardiol 2(2):127–135. https://doi.org/10.1001/jamacardio.2016.4556

    Article  PubMed  Google Scholar 

  32. Yerasi C, Case BC, Chezar-Azerrad C et al (2021) Cangrelor vs. glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention. Am Heart J 238:59–65. https://doi.org/10.1016/j.ahj.2021.04.013

  33. Silverio A, Buccheri S, Venetsanos D et al (2020) Percutaneous treatment and outcomes of small coronary vessels: a SCAAR report. JACC Cardiovasc Interv 13(7):793–804. https://doi.org/10.1016/j.jcin.2019.10.062

    Article  PubMed  Google Scholar 

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Funding

No funding was received for conducting this study.

Author information

Author notes

  1. Angelo Silverio and Michele Bellino equally contributed to this manuscript.

Authors and Affiliations

  1. Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081, Baronissi, Salerno, Italy

    Angelo Silverio, Michele Bellino, Mario Centore, Marco Di Maio, Luca Esposito, Giovanni Granata, Carmine Vecchione & Gennaro Galasso

  2. Cardiology Unit, Medical Sciences Departement, ASST Bergamo Est, Seriate, Bergamo, Italy

    Fernando Scudiero & Davide Personeni

  3. Interventional Cardiology Unit, University Hospital San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy

    Tiziana Attisano & Cesare Baldi

  4. Cardiology Unit, Hospital Maria SS. Addolorata, Eboli, Italy

    Angelo Catalano & Mario Centore

  5. Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’, Naples, Italy

    Arturo Cesaro & Paolo Calabrò

  6. Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy

    Luca Esposito

  7. Cardiology Department, Santa Croce e Carle Hospital, Cuneo, Italy

    Francesco Maiellaro

  8. Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy

    Iacopo Muraca & Renato Valenti

  9. Cardiology Department, Azienda Ospedaliera Ordine Mauriziano Umberto I, Turin, Italy

    Giuseppe Musumeci

  10. Cardiology Unit, Department of Medicine, Lavagna Hospital, Lavagna, Italy

    Guido Parodi

Authors
  1. Angelo Silverio
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  2. Michele Bellino
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Contributions

All authors have contributed to the manuscript.

- Conception and design or analysis and interpretation of data: A. Silverio, M. Bellino, F. Scudiero, M. Di Maio, M. Centore.

-Drafting of the manuscript: A. Silverio, M. Bellino, L. Esposito.

- Revising critically the manuscript: T. Attisano, C. Baldi, A. Catalano, A. Cesaro, G. Granata, F. Maiellaro, I. Muraca, G. Musumeci, G. Parodi, D. Personeni, R. Valenti.

- Final approval of the manuscript: Angelo Silverio, Michele Bellino, Fernando Scudiero, Tiziana Attisano, Cesare Baldi, Angelo Catalano, Mario Centore, Arturo Cesaro, Marco Di Maio, Luca Esposito, Giovanni Granata, Francesco Maiellaro, Iacopo Muraca, Giuseppe Musumeci, Guido Parodi, Davide Personeni, Renato Valenti, Carmine Vecchione, Paolo Calabrò, Gennaro Galasso.

Corresponding author

Correspondence to Angelo Silverio.

Ethics declarations

Ethics approval

The study was approved by the institutional ethics committee of the University Hospital of Salerno and conforms to the Declaration of Helsinki.

Consent to participate

All patients were informed of the nature and aims of the study and asked to sign an informed consent for the anonymous management of their data.

Competing interests

Dr. Luca Esposito received a research grant by the CardioPath program from the Federico II University of Naples, Italy. The other authors have no relevant financial or non-financial interests to disclose.

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Highlights

• The use of intravenous antiplatelet therapy during primary percutaneous coronary intervention (PPCI) is not fully standardized.

• This is the first multicentre study comparing the effectiveness and safety of cangrelor and tirofiban in a real-world population of patients with ST-segment elevation myocardial infarction (STEMI).

• Compared to tirofiban, the use of cangrelor was associated with a higher chance of successful myocardial reperfusion after PPCI, with no difference in terms of clinically-relevant bleedings during the hospitalization.

• Our study reinforces the role of cangrelor for periprocedural platelet inhibition during PPCI in patients with STEMI. These findings should be confirmed by future randomized clinical trials.

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Silverio, A., Bellino, M., Scudiero, F. et al. Intravenous antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. J Thromb Thrombolysis (2024). https://doi.org/10.1007/s11239-024-02970-7

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