Prehospital Administration of Ticagrelor Cuts Early Ischemic Events in STEMI Patients


LONDON, England—Giving ticagrelor to STEMI patients en route to the hospital reduces their risk of ischemic events in the 24 hours after primary PCI, according to results of a subset analysis of the ATLANTIC trial presented August 31, 2015, at the European Society of Cardiology Congress. 

The Take Home: Prehospital Administration of Ticagrelor Cuts Early Ischemic Events in STEMI Patients

In ATLANTIC, acute STEMI patients were randomized to prehospital ticagrelor (Brilinta; AstraZeneca)—a 180-mg loading dose of ticagrelor given before transfer, with a matching placebo in the cath lab—or to in-hospital ticagrelor consisting of a placebo before transfer and a 180-mg loading dose of the drug in the cath lab. All patients subsequently received ticagrelor 90 mg twice daily for 30 days with a recommendation to continue treatment for a total of 12 months. The main results showed that prehospital administration of the P2Y12 antagonist was safe, but did not improve pre-PCI coronary reperfusion of the culprit artery.

According to Gilles Montalescot, MD, PhD, of Centre Hospitalier Pitié-Salpêtrière (Paris, France), the suspicion that ticagrelor may not have improved pre-PCI reperfusion due to extremely rapid transfer times (mean 31 minutes) was the impetus for examining post-PCI outcomes in ATLANTIC-H24, a landmark exploratory analysis.

“We hypothesized that the effect of early ticagrelor may not have manifested until after PCI,” he said. For this study, the investigators therefore looked at ischemic outcomes within 24 hours of revascularization in 1,629 patients from ATLANTIC.

All Endpoints Reduced Except Death

The baseline characteristics of patients in ATLANTIC-H24 were similar to those of paitnets in the main analysis, with radial access used in nearly 70% and DES in 58%. Immediately after PCI, there was a slight increase in TIMI 3 flow in the prehospital ticagrelor group compared with the in-hospital group that was not significant, although “we didn’t even have such a signal before PCI” in the larger ATLANTIC cohort, Dr. Montalescot said. Coronary reperfusion rates also were numerically in favor of prehospital ticagrelor 1 hour after PCI, with a greater degree of ST-segment elevation resolution compared with the in-hospital group (median 75.0% vs 71.4%; P = .049). 

At 24 hours, the composite ischemic endpoint of death, MI, stent thrombosis, stroke, or urgent revascularization was less frequent in the prehospital ticagrelor group (10.4% vs 13.7%; P = .0389), as were the individual endpoints of definite stent thrombosis (P = .0078) and new MI (P = .0311). Bleeding was similar in both groups, and there was a trend favoring earlier administration of ticagrelor regarding bailout use of glycoprotein IIb/IIIa inhibitors.

However, prehospital administration of ticagrelor was associated with an increase in death in the first 24 hours (1.1% vs 0.2%; P = .0477).

Dr. Montalescot said most of those who died were elderly and died before ticagrelor may have had a chance to be effective. In conclusion, he said the take-home message of the study is that the early use of ticagrelor “may not pay off immediately” but its early use should be encouraged. 


Source:

Montalescot G. Effect of prehospital ticagrelor in STEMI patients in the first 24 hours after primary PCI: the ATLANTIC-H24 analysis. Presented at: European Society of Cardiology Congress; August 31, 2015; London, England. 

Disclosures:

  • The study was funded by AstraZeneca. 
  • Dr. Montalescot reports receiving consulting fees and grant support from multiple pharmaceutical companies. 

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