Downstream cangrelor versus upstream ticagrelor in patients with ST-segment elevation myocardial infarction: A propensity score-matched analysis

Int J Cardiol. 2025 Jan 1:418:132660. doi: 10.1016/j.ijcard.2024.132660. Epub 2024 Oct 18.

Abstract

Background: Pretreatment with a P2Y12 inhibitor may be considered in patients with ST-segment elevation myocardial infarction (STEMI) referred to percutaneous coronary intervention (PCI). Intravenous cangrelor is an alternative in this setting, where oral absorption can be hindered. The aim of this study was to compare cangrelor administered after coronary angiography (i.e., "downstream") and ticagrelor pretreatment (i.e., "upstream").

Methods: STEMI patients undergoing PCI from October 2019 to June 2023 were included. The primary outcome was the composite of in-hospital major adverse cardiovascular events (MACE). Secondary outcomes included individual components of the primary outcome and in-hospital major bleeding. Univariable and multivariable regression analyses were performed in unmatched and propensity-matched cohorts.

Results: Of 6086 patients enrolled in the prospective CAST registry, 761 were included: 383 (50.3 %) received downstream cangrelor and 378 (49.7 %) upstream ticagrelor. In the matched population, no between-group differences were observed in MACE (odds ratio [OR] 1.30; 95 % confidence interval [CI] 0.79-2.17; P 0.308), all-cause death (OR 1.91; 95 % CI 0.87-4.54; P 0.124), myocardial infarction (OR 2.64; 95 % CI 0.76-12.14; P 0.154), stent thrombosis (OR 0.38; 95 % CI 0.06-1.80; P 0.255), unplanned repeat revascularization (OR 1.22; 95 % CI 0.32-4.98; P 0.766) and major bleeding (OR 0.98; 95 % CI 0.50-1.93; P 0.955). Cardiogenic shock and bailout administration of glycoprotein IIb/IIIa inhibitors were independent predictors of MACE, while radial access showed an inverse association with the primary outc.

Conclusions: In P2Y12-naïve STEMI patients undergoing primary PCI, no significant differences were noted in the risk of in-hospital ischemic and bleeding events between downstream cangrelor and upstream ticagrelor.

Keywords: Acute coronary syndromes; Antiplatelet therapy; Cangrelor; ST-segment elevation myocardial infarction; Ticagrelor.

Publication types

  • Comparative Study

MeSH terms

  • Adenosine Monophosphate* / administration & dosage
  • Adenosine Monophosphate* / adverse effects
  • Adenosine Monophosphate* / analogs & derivatives
  • Adenosine Monophosphate* / therapeutic use
  • Aged
  • Coronary Angiography / methods
  • Female
  • Humans
  • Male
  • Middle Aged
  • Percutaneous Coronary Intervention* / methods
  • Platelet Aggregation Inhibitors / administration & dosage
  • Platelet Aggregation Inhibitors / therapeutic use
  • Propensity Score*
  • Prospective Studies
  • Purinergic P2Y Receptor Antagonists / administration & dosage
  • Purinergic P2Y Receptor Antagonists / therapeutic use
  • Registries
  • ST Elevation Myocardial Infarction* / drug therapy
  • ST Elevation Myocardial Infarction* / therapy
  • Ticagrelor* / administration & dosage
  • Ticagrelor* / therapeutic use
  • Treatment Outcome

Substances

  • cangrelor
  • Ticagrelor
  • Adenosine Monophosphate
  • Purinergic P2Y Receptor Antagonists
  • Platelet Aggregation Inhibitors