Cangrelor in cardiogenic shock and after cardiopulmonary resuscitation: A global, multicenter, matched pair analysis with oral P2Y12 inhibition from the IABP-SHOCK II trial

Droppa, Michal; Vaduganathan, Muthiah; Venkateswaran, Ramkumar V.; Singh, Amandeep; Szumita, Paul M.; Roberts, Russel J.; Qamar, Arman; Hack, Luis; Rath, Dominik; Gawaz, Meinrad; Fuernau, Georg; Waha‐Thiele, Suzanne de; Desch, Steffen; Schneider, Steffen; Ouarrak, Taoufik; Jaffer, Farouc A.; Zeymer, Uwe; Thiele, Holger; Bhatt, Deepak L.; Geisler, Tobias

doi:10.1016/j.resuscitation.2019.02.008

Cited by 39 publications

(27 citation statements)

References 38 publications

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“…There is currently no consensus on how to control exaggerated platelet consumption under ECLS. After careful exclusion of heparin-induced thrombocytopenia, pharmacological platelet inhibition with short-acting compounds (e.g., intravenous P2Y 12 inhibitor cangrelor) have been used in some case reports showing favorable outcome, 94 while bleeding was still frequent. 95 In an animal model and in vitro model of extracorporeal circulation (Chandler loop), administration of cangrelor led to a significant decrease of platelet activation and increase of platelet count under hypothermia.…”

Section: Management Of Periprocedural Antithrombotic Therapy In Cardimentioning

confidence: 99%

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice

et al. 2019

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As the number of, and the indications for, structural heart interventions are increasing worldwide, the optimal secondary prevention to reduce device thrombosis is becoming more important. To date, most of the recommendations are empiric. The current review discusses mechanisms behind device-related thrombosis, the available evidence with regard to antithrombotic regimen after cardiac device implantation, as well as providing an algorithm for identification of risk factors for device thrombogenicity and for management of device thrombosis after implantation of patent foramen ovale and left atrial appendage occluders, MitraClips/transcatheter mitral valve replacement, pacemaker leads, and left ventricular assist devices. Of note, the topic of antithrombotic therapy and thrombogenicity of prostheses in aortic position (transcatheter aortic valve replacement, surgical, mechanical, and bioprostheses) is not part of the present article and is discussed in detail in other contemporary focused articles.

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Section: Management Of Periprocedural Antithrombotic Therapy In Cardimentioning

confidence: 99%

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice

et al. 2019

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“…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 . In a recent observational study, Droppa et al matched 88 patients with CS treated with cangrelor to the same number of patients enrolled in the IABP‐SHOCK II trial who were not treated with cangrelor . They showed that cangrelor was not associated with improved 30‐day mortality, although trended to reduce 1‐year mortality (34.1 vs. 47.1%; p = .08).…”

Section: Adjunctive Antithrombotic Pharmacotherapymentioning

confidence: 97%

“…In the Efficacy Study of LV Assist Device to Treat Patients with Cardiogenic Shock (ISAR‐SHOCK) registry, 42% of patients with an acute coronary syndrome and CS treated with a thienopyridine had high‐platelet reactivity 5–6 hr following the loading dose . There are only a few observational studies on clinical outcomes to guide antiplatelet selection in patients with AMICS, as summarized in Table . In the ISAR‐SHOCK registry, 30‐day mortality was significantly lower in patients treated with prasugrel compared with clopidogrel (30 vs. 50%, respectively; p = .025), without excess in bleeding ( p = .571) .…”

Section: Adjunctive Antithrombotic Pharmacotherapymentioning

confidence: 99%

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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“…3,7 Cangrelor, at a dose of 0.75 µg/kg/min, given to patients in cardiogenic shock with an intra-aortic balloon pump, was associated with a similar bleeding risk, improved TIMI (thrombolysis in myocardial infarction) flow, and numerically lower mortality compared with matched controls treated with oral P2Y12 inhibitors. 8 In a case series of 13 patients post-PCI in cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) support who received a nontitrating dose of cangrelor 0.75 µg/kg/min, there were 10 (77%) hemorrhagic complications along with 1 (8%) thrombotic event. 2 Overall, further investigation is warranted for cangrelor use outside of periprocedural PCI, especially in combination with MCS.…”

Section: Introductionmentioning

confidence: 99%

Clinical Use of Cangrelor After Percutaneous Coronary Intervention in Patients Requiring Mechanical Circulatory Support

et al. 2021

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Background: Patients with cardiogenic shock after percutaneous coronary intervention (PCI) may require mechanical circulatory support (MCS). The combination of dual antiplatelet therapy with cangrelor and continuous anticoagulation required for MCS may increase the risk of bleeding. Objective: The objective of the study is to describe the complications and outcomes of patients who received cangrelor during MCS following PCI. Methods: This is a single-center, retrospective, observational case series of 17 patients who received cangrelor while on MCS from June 2017 to September 2019. Results: In a case series of 17 patients, 8 patients (47%) were supported with an Impella device and 4 patients (24%) with venoarterial (VA) extracorporeal membrane oxygenation (ECMO); 5 required (29%) concomitant VA ECMO and Impella support in the setting of cardiogenic shock. All patients received triple antithrombotic therapy with aspirin, heparin, and cangrelor. Cangrelor was commonly initiated at a median dose of 0.75 (range 0.5-4) µg/kg/min. Cangrelor dose adjustments included changes in increments up to 0.25 µg/kg/min with review of P2Y12 levels. A total of 10 patients (59%) experienced a bleeding event, most commonly located at the peripheral cannulation site (40%) and in the gastrointestinal tract (30%). Seven (70%) and 3 (30%) of the bleeding complications were classified as major and minor, respectively. No patient developed in-stent thrombosis during the hospitalization; 14 (82%) patients survived their MCS course. Conclusion and Relevance: This case series suggests that cangrelor doses less than 0.75 µg/kg/min may be beneficial. Larger studies should evaluate alternative dosing regimens.

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Cangrelor in cardiogenic shock and after cardiopulmonary resuscitation: A global, multicenter, matched pair analysis with oral P2Y12 inhibition from the IABP-SHOCK II trial

Cited by 39 publications

References 38 publications

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice

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

Clinical Use of Cangrelor After Percutaneous Coronary Intervention in Patients Requiring Mechanical Circulatory Support

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