Optimizing the Use of Cangrelor in the Real World

Arman Qamar; Deepak L. Bhatt

Disclosures

Am J Cardiovasc Drugs. 2017;17(1):5-16. 

In This Article

Cangrelor in Patients Undergoing Coronary Artery Bypass Graft

Current guidelines recommend discontinuing P2Y12 receptor inhibitors 5–7 days prior to CABG to minimize bleeding. Premature interruption in P2Y12 receptor blockade in ACS patients who were treated medically or with PCI is associated with an increase in the risk of thrombotic events.[70] On the contrary, continuation of P2Y12 receptor inhibitor during CABG increases the risk of bleeding complications. In the BRIDGE trial, 210 patients with ACS or with stents on clopidogrel or prasugrel awaiting CABG were randomized to receive either cangrelor (0.75 μg/kg/min infusion without a bolus) or placebo.[71] Clopidogrel or prasugrel were discontinued, and patients received either cangrelor or placebo for at least 48 h. Cangrelor was stopped 1–6 h before CABG. Patients treated with cangrelor maintained a higher rate of optimal platelet inhibition compared with placebo. The primary efficacy end point of percentage of patients with platelet reactivity less than 240 P2Y12 reaction units (PRU) was higher in patients treated with cangrelor than placebo (98.8 vs. 19.0 %) (relative risk 5.2; 95 % CI 3.3–8.1; P<0.001). Bridging with cangrelor did not result in a significant increase in major bleeding prior to CABG. While this study was not powered to answer if this approach would reduce ischemic events, these findings suggest a possible role of a bridging strategy with cangrelor to maintain optimal platelet inhibition after oral P2Y12 receptor inhibition is stopped in patients awaiting CABG (or potentially other surgeries). Currently, cangrelor is not approved for this indication. However, if a bridging strategy with an intravenous antiplatelet agent is chosen, cangrelor offers a more attractive profile than intravenous glycoprotein IIb/IIIa inhibitors.[72]

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