Читать книгу Interventional Cardiology - Группа авторов - Страница 322

Cangrelor is an intravenous antagonist of the P2Y12 receptor characterized by rapid, potent, predictable and reversible platelet inhibition [61]. The plasma half‐like of cangrelor is approximately 3 to 5 mins, and platelet function is restored within 1 h after cessation of the infusion. The CHAMPION PHOENIX trial [62], in contrast to the earlier CHAMPION PCI and CHAMPION PLATFORM trials [63,64], included STEMI patients (approx. 18%) in a randomization of 11,145 patients undergoing PCI to either a bolus of cangrelor or a loading dose of clopidogrel. Cangrelor significantly reduced the rate of ischemic events (adjusted OR 0.78; 95% CI 0.66–0.93; p = 0.005) without any significant increase in severe bleeding. The Platelet Inhibition With Cangrelor and Crushed Ticagrelor in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention (CANTIC) study has ruled out a significant drug‐drug interaction when cangrelor is used to “bridge the gap” in acute STEMI presentations prior to the onset of action of ticagrelor, but larger studies are needed to assess clinical endpoints [65]. Observational data from the SCAAR registry suggests similar efficacy at preventing stent thrombosis to the potent oral P2Y12 inhibitors [66].

However, a randomized trial in the UK, compared the use of ticagrelor vs cangrelor in 100 STEMI patients, and found that while platelet inhibition (as measured by platelet reactivity) at the time of initial balloon inflation was greater, this did not translate into a difference in angiographic and electrocardiographic measures of reperfusion, or a significant difference in final infarct size [67]. The FABOLUS FASTER trial [46] aimed to compare the effects of cangrelor, tirofiban, and prasugrel on early IPA in patients with STEMI undergoing primary PCI. A total of 122 P2Y12‐naïve patients were randomly allocated (1:1:1) to cangrelor, tirofiban or a 60‐mg loading dose of prasugrel, with the prasugrel group being subrandomized to chewed or integral tablets. At 30 minutes, cangrelor did not satisfy noninferiority compared with tirofiban (IPA for tirofiban 95.0 ± 8.9 vs 34.1 ± 22.5, p < 0.001). Cangrelor and tirofiban were both superior to chewed prasugrel. This study supports the use of cangrelor in a “bridge the gap” approach in acute STEMI but suggests that the antiplatelet effect of cangrelor is not a replacement for a potent GP IIb‐IIIa inhibitor, where use of the latter is deemed appropriate. Further studies are needed to assess how the results on IPA effect clinical endpoints.