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Tian R, Liu R, Zhang J, Li Y, Wei S, Xu F, Li X, Li C. Efficacy and safety of intracoronary versus intravenous tirofiban in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Heliyon 2023; 9:e15842. [PMID: 37180928 PMCID: PMC10172923 DOI: 10.1016/j.heliyon.2023.e15842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Background Effective antiplatelet therapy is critical for patients with ST-segment elevation myocardial infarction (STEMI) and receiving primary percutaneous coronary interventions (PPCI). Intracoronary (IC) and intravenous (IV) administration of tirofiban are commonly used during the procedure of PPCI. However, which is the better administration route of tirofiban have not been fully evaluated. Methods A comprehensive literature search of RCTs that comparing IC with IV tirofiban in STEMI patients undergoing PPCI was conducted, which were published as of May 7, 2022, in PubMed, Embase, Cochrane Library, Web of Science, Scopus and ClinicalTrials.gov. The primary efficacy endpoint was 30-day major adverse cardiovascular events (MACE) and the primary safety endpoint was in-hospital bleeding events. Results This meta-analysis included 9 trials involving 1177 patients. IC tirofiban significantly reduced the incidence of 30-day MACE (RR 0.65, 95% CI: 0.44 to 0.95, P = 0.028) and improved the rate of the thrombolysis in myocardial infarction (TIMI) grade 3 flow in high-dose (25 μg/kg) group (RR = 1.13, 95% CI: 0.99-1.30, P = 0.001), in-hospital (WMD 2.03, 95% CI: 1.03 to 3.02, P < 0.001), and 6-month left ventricular injection fraction (LVEF) (WMD 6.01, 95% CI: 5.02 to 6.99, P < 0.001) compared with IV. There was no significant difference in the incidences of in-hospital bleeding events (RR 0.96, 95% CI: 0.67 to 1.38, P = 0.82) and thrombocytopenia (RR 0.63, 95% CI: 0.26 to 1.57, P = 0.32) between the two groups. Conclusions IC tirofiban significantly improved the incidence of TIMI 3 in the high-dose group, in-hospital and 6-month LVEF, and reduced the 30-day MACE incidence without increasing the risk of bleeding compared with IV.
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Affiliation(s)
- Rui Tian
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Rugang Liu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Jiajun Zhang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yong Li
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Shujian Wei
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xiaoxing Li
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Chuanbao Li
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Franchi F, Ortega-Paz L, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Reiter B, Jilma B, Angiolillo DJ. Cangrelor in Patients With Coronary Artery Disease Pretreated With Ticagrelor: The Switching Antiplatelet (SWAP)-5 Study. JACC Cardiovasc Interv 2023; 16:36-46. [PMID: 36317958 DOI: 10.1016/j.jcin.2022.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are no studies specifically designed to rule out a drug-drug interaction (DDI) when cangrelor is used among patients who have been pretreated with ticagrelor. OBJECTIVES This study sought to rule out a DDI among cangrelor-treated patients who have been pretreated with ticagrelor. METHODS In this prospective, randomized, double-blind, placebo-controlled, crossover, pharmacokinetic (PK) and pharmacodynamic (PD) study, patients with coronary artery disease (N = 20) were pretreated with a 180-mg ticagrelor loading dose and after 1 hour randomized to placebo or cangrelor (bolus and infusion for 2 hours). Patients crossed over after 1 to 4 weeks of washout. PK analysis included ticagrelor plasma levels and its active metabolite. PD assessments included VerifyNow P2Y12 reaction units (PRU), light transmittance aggregometry, vasodilator-stimulated phosphoprotein, and Total Thrombus-Formation Analysis System. PK/PD assessments were performed at 7 time points. RESULTS Compared with placebo, adding cangrelor to patients pretreated with ticagrelor resulted in a significant reduction in PRU at 30 minutes and 1 hour after starting infusion. At 2 hours after stopping cangrelor/placebo infusion, PRU were low and similar in both groups (16.9 vs 12.6; mean difference: 4.3; 95% CI: -28.6 to 37.3), meeting the noninferiority primary endpoint (predefined noninferiority margin 45 PRU). Consistent findings were shown with all PD assays. PK tracked PD findings with no differences between groups in plasma levels of ticagrelor and its metabolite. CONCLUSIONS Compared with placebo, the use of cangrelor in patients pretreated with ticagrelor results in enhanced platelet inhibition with no differences in PK/PD profiles after discontinuation of drug infusion indicating the absence of a DDI. (PD and PK Profiles of Switching Between Cangrelor and Ticagrelor Following Ticagrelor Pre-treatment [SWAP-5]; NCT04634162).
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Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA; Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA.
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3
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Guo YZ, Zhao ZW, Li SM, Chen LL. Clinical efficacy and safety of tirofiban combined with conventional dual antiplatelet therapy in ACS patients undergoing PCI. Sci Rep 2021; 11:17144. [PMID: 34433885 PMCID: PMC8387390 DOI: 10.1038/s41598-021-96606-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 08/12/2021] [Indexed: 11/09/2022] Open
Abstract
Challenges remain for clinicians over balancing the efficacy of active antithrombotic therapy and simultaneous bleeding reduction in patients. The clinical data of 347 patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) were retrospectively analyzed. On the basis of the given tirofiban, the patients were assigned into three different dose groups: high dose group (group H), medium dose group (group M), and low dose group (group L). The tirofiban efficacy was evaluated in terms of major adverse cardiovascular event (MACE) parameters and lab endpoints, including platelet count and function. The tirofiban safety was assessed by the occurrence of bleeding events. The patients were followed up for 1 month after the PCI. No significant difference in MACE events was evident among these groups (p > 0.05). Groups H and M reported an obvious reduction in platelet count (p < 0.05 for both) and an increased platelet inhibition rate (p < 0.05 for both). Group H showed a higher rate of total bleeding events than the other groups (Group H vs. Group M: 34.4% vs. 16.5%; Group H vs. Group L: 34.4% vs. 10.3%; p < 0.05 for both). A proper administration of a low dose of tirofiban may be a superior alternative in treating ACS patients, which can produce a similar favorable clinical outcome and a decrease in bleeding complication.
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Affiliation(s)
- Yong-Zhe Guo
- Department of Cardiology, Fujian Medical University Union Hospital, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, China
| | - Zi-Wen Zhao
- Department of Cardiology, Fujian Medical University Union Hospital, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, China
| | - Shu-Mei Li
- Department of Cardiology, Fujian Medical University Union Hospital, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, China
| | - Liang-Long Chen
- Department of Cardiology, Fujian Medical University Union Hospital, 29 Xin-Quan Road, Fuzhou, 350001, Fujian, China.
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Reducing Cardiac Injury during ST-Elevation Myocardial Infarction: A Reasoned Approach to a Multitarget Therapeutic Strategy. J Clin Med 2021; 10:jcm10132968. [PMID: 34279451 PMCID: PMC8268641 DOI: 10.3390/jcm10132968] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 02/06/2023] Open
Abstract
The significant reduction in ‘ischemic time’ through capillary diffusion of primary percutaneous intervention (pPCI) has rendered myocardial-ischemia reperfusion injury (MIRI) prevention a major issue in order to improve the prognosis of ST elevation myocardial infarction (STEMI) patients. In fact, while the ischemic damage increases with the severity and the duration of blood flow reduction, reperfusion injury reaches its maximum with a moderate amount of ischemic injury. MIRI leads to the development of post-STEMI left ventricular remodeling (post-STEMI LVR), thereby increasing the risk of arrhythmias and heart failure. Single pharmacological and mechanical interventions have shown some benefits, but have not satisfactorily reduced mortality. Therefore, a multitarget therapeutic strategy is needed, but no univocal indications have come from the clinical trials performed so far. On the basis of the results of the consistent clinical studies analyzed in this review, we try to design a randomized clinical trial aimed at evaluating the effects of a reasoned multitarget therapeutic strategy on the prevention of post-STEMI LVR. In fact, we believe that the correct timing of pharmacological and mechanical intervention application, according to their specific ability to interfere with survival pathways, may significantly reduce the incidence of post-STEMI LVR and thus improve patient prognosis.
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5
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The use of cangrelor in neurovascular interventions: a multicenter experience. Neuroradiology 2020; 63:925-934. [PMID: 33174182 DOI: 10.1007/s00234-020-02599-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE Thromboembolic events represent the most common procedure-related complication associated with neurointerventions. Cangrelor is a potent, intravenous (IV), P2Y12-receptor antagonist with a rapid onset and offset presented as an alternative antiplatelet agent. We aim to evaluate the safety and effectiveness of IV cangrelor in neurovascular intervention. METHODS This is a retrospective analysis of data from four cerebrovascular interventional centers. We identified patients who underwent acute neurovascular intervention and received cangrelor as part of their optimum care. Patients were divided into 2 groups: ischemic and aneurysm. Periprocedural thromboembolic events, hemorrhagic complications, and outcomes were analyzed. RESULTS Sixty-six patients were included, 42 allocated into the ischemic group (IG), and 24 into aneurysm group (AG). The IG periprocedural symptomatic complication rate was 9.5%, represented by 3 postoperative intracranial hemorrhages and 1 retroperitoneal hematoma. At discharge, 47.6% had a favorable outcome and the mortality rate was 2.4%, related to clinical deterioration of a large infarct. In the AG, 4.2% had a periprocedural complication during or after cangrelor infusion, represented by an intracranial hemorrhage in an initially ruptured aneurysm. Favorable clinical outcome was seen in 56.2% and 87.7% of ruptured and unruptured aneurysms, respectively, upon discharge. CONCLUSIONS Cangrelor may be a feasible alternative for patients requiring immediate intervention with the use of endoluminal devices. It allows the possibility for a secure transition to long-term ticagrelor and progression to surgery in the setting of unexpected complications.
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6
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Tavenier AH, Hermanides RS, Ottervanger JP, Tolsma R, van Beurden A, Slingerland RJ, ter Horst PGJ, Gosselink ATM, Dambrink JHE, van Leeuwen MAH, Roolvink V, Kedhi E, Klungel OH, Belitser SV, Angiolillo DJ, Pustjens T, Rasoul S, Gho B, Stein M, Ruiters L, van ‘t Hof AWJ. Impact of opioids on P2Y12 receptor inhibition in patients with ST-elevation myocardial infarction who are pre-treated with crushed ticagrelor: Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:4-12. [PMID: 32730628 PMCID: PMC8728016 DOI: 10.1093/ehjcvp/pvaa095] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/19/2020] [Accepted: 07/23/2020] [Indexed: 01/09/2023]
Abstract
Aims Platelet inhibition induced by P2Y12 receptor antagonists in patients with ST-elevation myocardial infarction (STEMI) can be affected by concomitant use of opioids. The aim of this trial was to examine the effect of intravenous (iv) acetaminophen compared with iv fentanyl on P2Y12 receptor inhibition in patients with STEMI. Methods and results The Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial randomized 195 STEMI patients who were scheduled to undergo primary percutaneous coronary intervention (PCI) and were pre-treated with crushed ticagrelor to iv acetaminophen (N = 98) or iv fentanyl (N = 97) in the ambulance. The primary endpoint, consisting of the level of platelet reactivity units (PRU) measured immediately after primary PCI, was not significantly different between the study arms [median PRU 104 (IQR 37–215) vs. 175 (63–228), P = 0.18]. However, systemic levels of ticagrelor were significantly higher in the acetaminophen arm at the start of primary PCI [151 ng/mL (32–509) vs. 60 ng/mL (13–206), P = 0.007], immediately after primary PCI [326 ng/mL (94–791) vs. 115 ng/mL (38–326), P = 0.002], and at 1 h after primary PCI [488 ng/mL (281–974) vs. 372 ng/mL (95–635), P = 0.002]. Acetaminophen resulted in the same extent of pain relief when compared with fentanyl [reduction of 3 points on 10-step-pain scale before primary PCI (IQR 1–5)] in both study arms (P = 0.67) and immediately after PCI [reduction of 5 points (3–7); P = 0.96]. Conclusion The iv acetaminophen in comparison with iv fentanyl was not associated with significantly lower platelet reactivity in STEMI patients but resulted in significantly higher ticagrelor plasma levels and was effective in pain relief.
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Affiliation(s)
| | - Renicus S Hermanides
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Jan Paul Ottervanger
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Rudolf Tolsma
- Ambulancedienst IJsselland, Voltastraat 3-A, 8013 PM Zwolle, The Netherlands
| | | | | | | | - A T Marcel Gosselink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Jan-Henk E Dambrink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Maarten A H van Leeuwen
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Vincent Roolvink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Elvin Kedhi
- Department of Cardiology, AZ Sint-Jan, Brugge, Belgium
| | - Olaf H Klungel
- Department of Pharmacoepidemiology, University of Utrecht, Utrecht, The Netherlands
| | - Svetlana V Belitser
- Department of Pharmacoepidemiology, University of Utrecht, Utrecht, The Netherlands
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Tobias Pustjens
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Saman Rasoul
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Ben Gho
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Mera Stein
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Lex Ruiters
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Arnoud W J van ‘t Hof
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
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7
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Gargiulo G, Esposito G, Avvedimento M, Nagler M, Minuz P, Campo G, Gragnano F, Manavifar N, Piccolo R, Tebaldi M, Cirillo P, Hunziker L, Vranckx P, Leonardi S, Heg D, Windecker S, Valgimigli M. Cangrelor, Tirofiban, and Chewed or Standard Prasugrel Regimens in Patients With ST-Segment-Elevation Myocardial Infarction: Primary Results of the FABOLUS-FASTER Trial. Circulation 2020; 142:441-454. [PMID: 32795098 PMCID: PMC7392586 DOI: 10.1161/circulationaha.120.046928] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Standard administration of newer oral P2Y12 inhibitors, including prasugrel or ticagrelor, provides suboptimal early inhibition of platelet aggregation (IPA) in patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention. We aimed to investigate the effects of cangrelor, tirofiban, and prasugrel, administered as chewed or integral loading dose, on IPA in patients undergoing primary percutaneous coronary intervention. Methods: The FABOLUS-FASTER trial (Facilitation Through Aggrastat or Cangrelor Bolus and Infusion Over Prasugrel: A Multicenter Randomized Open-Label Trial in Patients with ST-Elevation Myocardial Infarction Referred for Primary Percutaneous Intervention) is an investigator-initiated, multicenter, open-label, randomized study. A total of 122 P2Y12-naive patients with ST-segment–elevation myocardial infarction were randomly allocated (1:1:1) to cangrelor (n=40), tirofiban (n=40) (both administered as bolus and 2-hour infusion followed by 60 mg of prasugrel), or 60-mg loading dose of prasugrel (n=42). The latter group underwent an immediate 1:1 subrandomization to chewed (n=21) or integral (n=21) tablets administration. The trial was powered to test 3 hypotheses (noninferiority of cangrelor compared with tirofiban using a noninferiority margin of 9%, superiority of both tirofiban and cangrelor compared with chewed prasugrel, and superiority of chewed prasugrel as compared with integral prasugrel, each with α=0.016 for the primary end point, which was 30-minute IPA at light transmittance aggregometry in response to 20 μmol/L adenosine diphosphate. Results: At 30 minutes, cangrelor did not satisfy noninferiority compared with tirofiban, which yielded superior IPA over cangrelor (95.0±8.9 versus 34.1±22.5; P<0.001). Cangrelor or tirofiban were both superior to chewed prasugrel (IPA, 10.5±11.0; P<0.001 for both comparisons), which did not provide higher IPA over integral prasugrel (6.3±11.4; P=0.47), despite yielding higher prasugrel active metabolite concentration (ng/mL; 62.3±82.6 versus 17.1±43.5; P=0.016). Conclusions: Cangrelor provided inferior IPA compared with tirofiban; both treatments yielded greater IPA compared with chewed prasugrel, which led to higher active metabolite concentration but not greater IPA compared with integral prasugrel. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02978040; URL: https://www.clinicaltrialsregister.eu; EudraCT 2017-001065-24.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital (M.N.), University of Bern, Switzerland
| | - Pietro Minuz
- Department of Medicine, Unit of General Medicine for the Study and Treatment of Hypertensive Disease, University of Verona, Policlinico GB Rossi, Italy (P.M.)
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Italy (G.C., M.T.)
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy (G.C.)
| | - Felice Gragnano
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli,” Naples, Italy (F.G.)
| | - Negar Manavifar
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Matteo Tebaldi
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Italy (G.C., M.T.)
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G., G.E., M.A., R.P., P.C.)
| | - Lukas Hunziker
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Belgium (P.V.)
| | - Sergio Leonardi
- University of Pavia and Fondazione IRCCS Policlinico S Matteo, Italy (S.L.)
| | - Dik Heg
- Bern University Hospital, and Clinical Trials Unit, CTU Bern (D.H.), University of Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology (G.G., F.G., N.M., L.H., S.W., M.V.), University of Bern, Switzerland
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