cangrelor and Shock--Cardiogenic

Cangrelor has a potentially favorable pharmacodynamic profile in cardiogenic shock (CS). We aimed to evaluate the clinical course of CS patients undergoing percutaneous coronary intervention (PCI) treated with cangrelor.. Cangrelor treatment was associated with similar bleeding risk and significantly better TIMI flow improvement compared with oral P2Y

Topics: Acute Coronary Syndrome; Adenosine Monophosphate; Administration, Oral; Aged; Combined Modality Therapy; Female; Humans; Male; Matched-Pair Analysis; Middle Aged; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Purinergic P2Y Receptor Antagonists; Retrospective Studies; Shock, Cardiogenic

VA-ECMO is commonly used for patients in cardiogenic shock (CS) or refractory cardiac arrest (CA) undergoing PCI for ACS. In this setting at high risk of both thrombotic and hemorrhagic complications, optimal anti-thrombotic therapy remains ill-defined. We hypothesized that an anti-thrombotic therapy comprising a parenteral anticoagulant (bivalirudin) and a parenteral anti-platelet agent (cangrelor) may prove safe and effective in this scenario. From November 2019 to December 2021, 14 patients received at least one dose of cangrelor (starting dose: 0.125 μg/kg/min) plus bivalirudin, without background aspirin, in the context of PCI and VA-ECMO for ACS-related CS/CA, and were included in this study. Efficacy endpoint was occurrence of thrombotic events and safety endpoint was major bleeding occurrence. Median age was 58 years. The majority (64%) presented with refractory CA. A thrombotic event occurred in 14%, while major bleeding occurred in 21% patients. One patient experienced arterial thrombosis after VA-ECMO arterial cannula removal, another experienced ischemic cerebellar stroke without functional sequelae. Bleeding events were: 29% BARC 3a, 14% BARC 3b, and 7% BARC 5b. Overall in-hospital mortality was 50%. Cangrelor was continued for 5 (4-10) days; temporary discontinuation was necessary in 36%, either for VA-ECMO cannula removal or for bleeding events. A low dose of cangrelor, associated with standard-intensity anticoagulation with bivalirudin was a feasible anti-thrombotic strategy in patients undergoing PCI during VA-ECMO support for ACS-related CS/CA. Bleeding events rates outweighed thrombotic events rates in this critically-ill population, although the observed rates were lowest among available studies.

Topics: Extracorporeal Membrane Oxygenation; Hemorrhage; Humans; Middle Aged; Percutaneous Coronary Intervention; Retrospective Studies; Shock, Cardiogenic; Thrombosis; Treatment Outcome

Topics: Heart Arrest; Humans; Myocardial Infarction; Percutaneous Coronary Intervention; Shock, Cardiogenic; Treatment Outcome

Patients with cardiogenic shock after percutaneous coronary intervention (PCI) may require mechanical circulatory support (MCS). The combination of dual antiplatelet therapy with cangrelor and continuous anticoagulation required for MCS may increase the risk of bleeding.. The objective of the study is to describe the complications and outcomes of patients who received cangrelor during MCS following PCI.. This is a single-center, retrospective, observational case series of 17 patients who received cangrelor while on MCS from June 2017 to September 2019.. In a case series of 17 patients, 8 patients (47%) were supported with an Impella device and 4 patients (24%) with venoarterial (VA) extracorporeal membrane oxygenation (ECMO); 5 required (29%) concomitant VA ECMO and Impella support in the setting of cardiogenic shock. All patients received triple antithrombotic therapy with aspirin, heparin, and cangrelor. Cangrelor was commonly initiated at a median dose of 0.75 (range 0.5-4) µg/kg/min. Cangrelor dose adjustments included changes in increments up to 0.25 µg/kg/min with review of P2Y12 levels. A total of 10 patients (59%) experienced a bleeding event, most commonly located at the peripheral cannulation site (40%) and in the gastrointestinal tract (30%). Seven (70%) and 3 (30%) of the bleeding complications were classified as major and minor, respectively. No patient developed in-stent thrombosis during the hospitalization; 14 (82%) patients survived their MCS course.. This case series suggests that cangrelor doses less than 0.75 µg/kg/min may be beneficial. Larger studies should evaluate alternative dosing regimens.

Topics: Adenosine Monophosphate; Humans; Percutaneous Coronary Intervention; Retrospective Studies; Shock, Cardiogenic

Topics: Adenosine Monophosphate; Coronary Occlusion; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Purinergic P2Y Receptor Antagonists; Shock, Cardiogenic; Treatment Outcome

Bleeding frequently occurs in patients undergoing placement of a left ventricular assist device (LVAD). Clinical factors that have been identified as contributing to peri-procedural bleeding include LVAD implantation after an acute myocardial infarction and preoperative use of antiplatelet agents. In this report, we describe the use of cangrelor for preoperative antiplatelet bridging to LVAD in five post myocardial infarction patients with cardiogenic shock that had recently undergone percutaneous coronary intervention. During the cangrelor bridging period, no cases of thrombotic or major bleeding events occurred. During the first week following LVAD implantation, two patients experienced a major bleeding (each case required chest exploration for suspected hemorrhage). To our knowledge, this is the first series describing cangrelor use for antiplatelet bridging in patients undergoing LVAD implantation. While this series suggest cangrelor could possibly be a safe and effective antiplatelet bridging strategy, further research is needed to identify the optimal antithrombotic strategy in cardiogenic shock patients undergoing LVAD implantation who have recently undergoing percutaneous coronary intervention.

Topics: Adenosine Monophosphate; Aged; Cardiovascular Surgical Procedures; Female; Heart Ventricles; Heart-Assist Devices; Hemorrhage; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Shock, Cardiogenic

Patients with acute coronary syndromes (ACS) presenting with cardiogenic shock (CS) are at particular risk for death and adverse cardiac events. Impaired effects and absorption of oral P2Y12-receptor inhibitors due to decreased organ hypoperfusion or hypothermia and challenges regarding oral administration contribute to this risk. We report a single center experience regarding the use of intravenous P2Y12-receptor inhibitor cangrelor in patients with CS treated with percutaneous coronary intervention (PCI).. Twelve patients with ACS and CS undergoing PCI, not pretreated with oral P2Y12-receptor inhibitors, were treated with cangrelor. Platelet inhibition was assessed by multiple electrode aggregometry (MEA) before and after PCI, immediately and 2 hours after stopping the cangrelor infusion.. Nine patients recovered from their cardiogenic shock, 3 patients died. Platelet reactivity decreased from 65.9 (SD 41.0) U before PCI to 15.8 (SD 10.8) U after PCI, 13.4 (SD 7.7) U at the end of infusion and 33.8 (SD 19.9) 2 hours after stopping the cangrelor infusion. There was no non-responder under cangrelor infusion (MEA < 46 U).. Due to its favorable PK/PD profile, cangrelor overcomes problems with reduced absorption and effects of oral P2Y12-receptor inhibitors and should be considered for periprocedural treatment of patients with CS.

Topics: Acute Coronary Syndrome; Adenosine Monophosphate; Administration, Intravenous; Aged; Cardiotonic Agents; Female; Gene Expression; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Platelet Aggregation; Platelet Aggregation Inhibitors; Purinergic P2Y Receptor Antagonists; Receptors, Purinergic P2Y; Shock, Cardiogenic; Survival Analysis

Topics: Adenosine Monophosphate; Humans; Shock, Cardiogenic; Stents; Treatment Outcome

Topics: Adenosine Monophosphate; Humans; Shock, Cardiogenic; Treatment Outcome

Topics: Abciximab; Adenosine Monophosphate; Humans; Immunoglobulin Fab Fragments; Shock, Cardiogenic

Topics: Abciximab; Adenosine Monophosphate; Humans; Immunoglobulin Fab Fragments; Shock, Cardiogenic