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Intravenous Platelet Blockade with Cangrelor During PCI

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Intravenous Platelet Blockade with Cangrelor During PCI The new england journal of medicine original article Intravenous Platelet Blockade with Cangrelor during PCI Deepak L. Bhatt, M.D., M.P.H., A. Michael Lincoff, M.D., C. Michael Gibson, M.D., Gregg W. Stone, M.D., Steven McNulty, M.S., Gilles Montalescot, M.D., Ph.D., Neal S. Kleiman, M.D., Shaun G. Goodman, M.D., Harvey D. White, D.Sc., Kenneth W. Mahaffey, M.D., Charles V. Pollack, Jr., M.D., Steven V. Manoukian, M.D., Petr Widimsky, M.D., Dr.Sc., Derek P. Chew, M.B., B.S., M.P.H., Fernando Cura, M.D., Ivan Manukov, M.D., Frantisek Tousek, M.D., M. Zubair Jafar, M.D., Jaspal Arneja, M.D., Simona Skerjanec, Pharm.D., and Robert A. Harrington, M.D., for the CHAMPION PLATFORM Investigators* Abstract Background Intravenous cangrelor, a rapid-acting, reversible adenosine diphosphate (ADP) recep- The authors’ affiliations are listed in the tor antagonist, might reduce ischemic events during percutaneous coronary interven- Appendix. Address reprint requests to Dr. Bhatt at VA Boston Healthcare System, tion (PCI). 1400 VFW Pkwy., Boston, MA 02132, or at [email protected]. Methods In this double-blind, placebo-controlled study, we randomly assigned 5362 patients *Investigators in the Cangrelor versus Standard Therapy to Achieve Optimal who had not been treated with clopidogrel to receive either cangrelor or placebo at Management of Platelet Inhibition the time of PCI, followed by 600 mg of clopidogrel. The primary end point was a (CHAMPION) PLATFORM trial are listed composite of death, myocardial infarction, or ischemia-driven revascularization at in the Supplementary Appendix, avail- able with the full text of this article at 48 hours. Enrollment was stopped when an interim analysis concluded that the NEJM.org. trial would be unlikely to show superiority for the primary end point. This article (10.1056/NEJMoa0908629) Results was published on November 15, 2009, at NEJM.org. The primary end point occurred in 185 of 2654 patients receiving cangrelor (7.0%) and in 210 of 2641 patients receiving placebo (8.0%) (odds ratio in the cangrelor N Engl J Med 2009;361. group, 0.87; 95% confidence interval [CI], 0.71 to 1.07; P = 0.17) (modified intention- Copyright © 2009 Massachusetts Medical Society. to-treat population adjusted for missing data). In the cangrelor group, as compared with the placebo group, two prespecified secondary end points were significantly reduced at 48 hours: the rate of stent thrombosis, from 0.6% to 0.2% (odds ratio, 0.31; 95% CI, 0.11 to 0.85; P = 0.02), and the rate of death from any cause, from 0.7% to 0.2% (odds ratio, 0.33; 95% CI, 0.13 to 0.83; P = 0.02). There was no significant differ- ence in the rate of blood transfusion (1.0% in the cangrelor group and 0.6% in the placebo group, P = 0.13), though major bleeding on one scale was increased in the cangrelor group, from 3.5% to 5.5% (P<0.001), because of more groin hematomas. Conclusions The use of periprocedural cangrelor during PCI was not superior to placebo in re- ducing the primary end point. The prespecified secondary end points of stent thrombosis and death were lower in the cangrelor group, with no significant in- crease in the rate of transfusion. Further study of intravenous ADP blockade with cangrelor may be warranted. (ClinicalTrials.gov number, NCT00385138.) 10.1056/nejmoa0908629 nejm.org 1 Downloaded from www.nejm.org on November 15, 2009 . For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved. The new england journal of medicine lockade of the platelet adenosine PCI trial,16 which compared the use of cangrelor diphosphate (ADP) receptor has been dem- with the use of 600 mg of clopidogrel given at the Bonstrated to improve cardiovascular out- start of the PCI procedure, are also reported in comes in patients undergoing percutaneous cor- this issue of the Journal. o n a r y i n t e r v e n t i o n ( P C I ) . 1-5 I n p a t i e n t s u n d e r g o i n g coronary stenting, ticlopidine given with aspirin Methods was found to decrease the risk of stent thrombo- sis and other important ischemic complications, Patients as compared with aspirin alone or aspirin plus A total of 5362 patients who provided consent warfarin.6 Ticlopidine was ultimately replaced by were enrolled at 218 sites in 18 countries from clopidogrel as the ADP-receptor blocker of choice October 2006 through May 2009. Patients under- because of the drug’s improved profile for side went randomization according to a double-blind, effects and adverse events.7 placebo-controlled, double-dummy design to re- Despite its efficacy, clopidogrel has a delayed ceive either cangrelor (in a bolus of 30 μg per onset of action, even when given with a loading kilogram of body weight and an infusion of 4 μg dose; it also does not provide complete ADP-recep- per kilogram per minute) or a placebo bolus and tor inhibition and has substantial variability among infusion for the duration of the PCI procedure, patients.8 Even in the contemporary era, the vex- with a minimum infusion duration of 2 hours ing problem of acute stent thrombosis has not and a maximum of 4 hours. Patients in the can- been eliminated.9,10 Moreover, many physicians grelor group received 600 mg of clopidogrel after refrain from administering clopidogrel before ob- the end of the cangrelor infusion, and those in taining angiographic definition of the coronary the placebo group received 600 mg of clopidogrel anatomy, since this irreversible platelet inhibitor at the end of the procedure (Fig. 1). has been associated with an increased risk of Inclusion criteria for the trial were an age of perioperative bleeding if coronary-artery bypass at least 18 years, diagnostic coronary angiogra- grafting (CABG) is required rather than PCI. In phy revealing at least one atherosclerotic lesion addition, more potent oral ADP-receptor blockers amenable to PCI with or without stent implanta- have been tested and found to reduce ischemic tion, and evidence of either myocardial infarction outcomes even further but also increase the rate without ST-segment elevation or unstable angina. of bleeding.11-15 Therefore, an even more potent Patients with stable angina were initially eligible intravenous agent with fast onset and fast offset at the beginning of the trial before a protocol of action might provide a desirable combination amendment. The diagnosis of non–ST-segment of protection from ischemia without an excessive elevation myocardial infarction required a level risk of bleeding. of troponin I or troponin T that was higher than Cangrelor (the Medicines Company) is an ade- the upper limit of the normal range within 24 nosine triphosphate analogue that reversibly binds hours before randomization (or if troponin re- to and inhibits the P2Y12 ADP receptor. It has a sults were unavailable at that time, a level of half-life of 3 to 6 minutes and, when given as a creatine kinase–myocardial band [CK-MB] isoen- bolus plus infusion, quickly and consistently in- zyme that was higher than the upper limit of the hibits platelets to a high degree, with normaliza- normal range). The diagnosis of unstable angina tion of platelet function within 60 minutes after required ischemic chest discomfort occurring at discontinuation. In the Cangrelor versus Standard rest and lasting for at least 10 minutes within 24 Therapy to Achieve Optimal Management of hours before randomization and dynamic electro- Platelet Inhibition (CHAMPION) PLATFORM trial, cardiographic changes; an age of 65 years or older which we report here, we examined the efficacy or the presence of diabetes mellitus (or both) was of cangrelor versus placebo administered to pa- also required. All patients provided written in- tients during PCI, with patients in the placebo formed consent. group subsequently receiving a loading dose of Exclusion criteria included the use of any 600 mg of clopidogrel at the end of the revascu- thienopyridine in the previous 7 days, a planned larization procedure and patients in the cangrelor staged PCI procedure in which the second stage group receiving 600 mg of clopidogrel at the end would occur within 30 days after the first proce- of the infusion. The results of the CHAMPION dure, admission planned within 12 hours after 2 10.1056/nejmoa0908629 nejm.org Downloaded from www.nejm.org on November 15, 2009 . For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved. Intravenous Platelet Blockade with Cangrelor during PCI PCI, the occurrence of myocardial infarction with ST-segment elevation within 48 hours before ran- 5301 Patients requiring PCI (with or domization, known or suspected pregnancy, lac- without stent, excluding STEMI) tation, increased bleeding risk (the occurrence of underwent randomization ischemic stroke within the previous year or any previous hemorrhagic stroke), intracranial tumor, cerebral arteriovenous malformation, intracranial aneurysm, trauma or major surgery (including 2656 Received cangrelor, 30 µg/kg 2645 Received placebo, 30 µg/kg CABG) within the previous month, current war- bolus and 2654 received 4 µg/kg/min bolus and 4 µg/kg/min infusion infusion for ≥2 hr or the duration of for ≥2 hr or the duration of the farin use, active bleeding, a known international the procedure, whichever was longer procedure, whichever was longer normalized ratio of more than 1.5, a past or pres- ent bleeding disorder, a platelet count of less than 100,000 per cubic millimeter, severe hyper- 2627 Received 600-mg placebo 2620 Received 600-mg clopidogrel tension (systolic blood pressure, >180 mm Hg; or capsules immediately after capsules immediately after diastolic blood pressure, >110 mm Hg), or the procedure procedure use of fibrinolytic therapy or a glycoprotein IIb/ IIIa inhibitor in the 12 hours preceding random- ization.
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