COMMENTARY

ATLANTIC: Prehospital vs Cath Lab Ticagrelor in Primary PCI

Gilles Montalescot, MD, PhD

Disclosures

October 10, 2014

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Hello. My name is Gilles Montalescot. I am an interventional cardiologist, and I am here in Barcelona for the European Society of Cardiology meeting, where we presented the results of the ATLANTIC study in the Hot Line Session.[1,2] This study looked at the use of ticagrelor (Brillinta®) in the prehospital setting vs later administration of ticagrelor in the hospital in patients presenting with ST-segment elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PCI). The idea was to look at coronary artery perfusion before angioplasty on the ECG to assess ST segment resolution, and on the cinefilm to see whether we had better thrombolysis in myocardial infarction (TIMI) flow in these patients. We also performed a platelet function substudy to look at the effect of the drug, and we looked at clinical endpoints in a study with almost 2000 patients.

Our findings are quite clear: The administration of ticagrelor at first medical contact did not significantly affect coronary artery perfusion. There was no impact on ST segment resolution and no impact on TIMI flow before the angioplasty. However, a platelet effect appeared after PCI; the largest difference that we found between the two groups is visible approximately one hour after PCI. This difference was associated with better ST resolution at that time and a significant reduction in stent thrombosis. All stent thrombosis events occurred only in the group of patients treated late with ticagrelor. There was no stent thrombosis in the prehospital group up to five days. At 30 days we had confirmation of this difference, with a 1.2% stent thrombosis rate for the late administration of ticagrelor vs 0.2% in the prehospital-treated group—a significant difference for stent thrombosis. Safety was exactly the same in the two groups. We had several definitions of bleeding, and even minor bleeding did not differ between the two groups.

The conclusions are straightforward. We have a strategy of the early use of ticagrelor at first medical contact, which is safe and associated with a reduction in stent thrombosis, but we cannot expect a real benefit on coronary artery reperfusion before angioplasty. This study is probably important because it supports the current European guidelines,[3] which are quite firm in saying that this type of treatment should be administered at first medical contact, but until now we didn't have a single randomized study to support it. This class 1 recommendation is now supported by a randomized study performed with ticagrelor. Thank you very much for your attention.

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