Download PDF
CC BY 4.0 · TH Open 2020; 04(04): e437-e445
DOI: 10.1055/s-0040-1721504
Original Article

Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience

Roberta Rossini   *
1   Ospedale Santa Croce e Carle, Cuneo, Italy
,
Giulia Masiero    *
1   Ospedale Santa Croce e Carle, Cuneo, Italy
,
Claudia Fruttero
1   Ospedale Santa Croce e Carle, Cuneo, Italy
,
Enrico Passamonti
2   Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
,
Elba Calvaruso
2   Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
,
Moreno Cecconi
3   Ospedale di Civitanova Marche, Civitanova Marche, Italy
,
Cesare Carlucci
3   Ospedale di Civitanova Marche, Civitanova Marche, Italy
,
Marco Mojoli
4   Ospedale Santa Maria degli Angeli, Pordenone, Pordenone, Italy
,
Parodi Guido
5   Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
,
Giuseppe Talanas
5   Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
,
Simona Pierini
6   P.O. BASSINI—ASST Nord Milano, U.O.C. Cardiologia, Milano, Italy
,
Paolo Canova
7   ASST Papa Giovanni XXIII, Unità di Cardiologia 2, Bergamo, Italy
,
Nicoletta De Cesare
8   Policlinico san Marco, IOB, Zingonia-Osio Sotto, Bergamo, Italy
,
Stefania Luceri
9   Cardiology Division, Ospedale Mauriziano, Torino, Italy
,
Nicoletta Barzaghi
1   Ospedale Santa Croce e Carle, Cuneo, Italy
,
Giulio Melloni
1   Ospedale Santa Croce e Carle, Cuneo, Italy
,
Giorgio Baralis
1   Ospedale Santa Croce e Carle, Cuneo, Italy
,
Alessandro Locatelli
1   Ospedale Santa Croce e Carle, Cuneo, Italy
,
Giuseppe Musumeci
1   Ospedale Santa Croce e Carle, Cuneo, Italy
,
Dominick J. Angiolillo
10   University of Florida College of Medicine, Jacksonville, Florida, United States
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Objective The aim of the study is to describe the real-world use of the P2Y12 inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT).

Materials and Methods We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used.

Results Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was <2 g/dL; nine patients received blood transfusions consistent with the type of surgery, but no life-threatening or fatal bleeding occurred.

Conclusion Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.

Keywords

antiplatelet therapy - stent - surgery - bridging - cangrelor

* These authors contributed equally to this work.




Publication History

Received: 16 October 2019

Accepted: 02 November 2020

Article published online:
23 December 2020

© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Capodanno D, Alfonso F, Levine GN, Valgimigli M, Angiolillo DJ. ACC/AHA versus ESC guidelines on dual antiplatelet therapy: JACC guideline comparison. J Am Coll Cardiol 2018; 72 (23 Pt A): 2915-2931
    CrossrefPubMedSearch in Google Scholar
  • 2 Rossini R, Musumeci G, Capodanno D. et al. Perioperative management of oral antiplatelet therapy and clinical outcomes in coronary stent patients undergoing surgery. Results of a multicentre registry. Thromb Haemost 2015; 113 (02) 272-282
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Schouten O, van Domburg RT, Bax JJ. et al. Noncardiac surgery after coronary stenting: early surgery and interruption of antiplatelet therapy are associated with an increase in major adverse cardiac events. J Am Coll Cardiol 2007; 49 (01) 122-124
    CrossrefPubMedSearch in Google Scholar
  • 4 Capodanno D, Angiolillo DJ. Management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery. Circulation 2013; 128 (25) 2785-2798
    CrossrefPubMedSearch in Google Scholar
  • 5 Valgimigli M, Bueno H, Byrne RA. et al; ESC Scientific Document Group, ESC Committee for Practice Guidelines (CPG), ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: the task force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39 (03) 213-260
    CrossrefPubMedSearch in Google Scholar
  • 6 Rossini R, Angiolillo DJ, Musumeci G. et al. Antiplatelet therapy and outcome in patients undergoing surgery following coronary stenting: results of the surgery after stenting registry. Catheter Cardiovasc Interv 2017; 89 (01) E13-E25
    CrossrefPubMedSearch in Google Scholar
  • 7 Bhatt DL, Stone GW, Mahaffey KW. et al; CHAMPION PHOENIX Investigators. Effect of platelet inhibition with cangrelor during PCI on ischemic events. N Engl J Med 2013; 368 (14) 1303-1313
    CrossrefPubMedSearch in Google Scholar
  • 8 Angiolillo DJ, Schneider DJ, Bhatt DL. et al. Pharmacodynamic effects of cangrelor and clopidogrel: the platelet function substudy from the cangrelor versus standard therapy to achieve optimal management of platelet inhibition (CHAMPION) trials. J Thromb Thrombolysis 2012; 34 (01) 44-55
    CrossrefPubMedSearch in Google Scholar
  • 9 Angiolillo DJ, Firstenberg MS, Price MJ. et al; BRIDGE Investigators. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA 2012; 307 (03) 265-274
    CrossrefPubMedSearch in Google Scholar
  • 10 Bowman S, Gass J, Weeks P. Antiplatelet therapy bridging with cangrelor in patients with coronary stents: a case series. Ann Pharmacother 2019; 53 (02) 171-177
    CrossrefPubMedSearch in Google Scholar
  • 11 Van Tuyl JS, Newsome AS, Hollis IB. Perioperative bridging with glycoprotein IIb/IIIa inhibitors versus cangrelor: balancing efficacy and safety. Ann Pharmacother 2019; 53 (07) 726-737
    CrossrefPubMedSearch in Google Scholar
  • 12 Stern G, Rimsans J, Qamar A, Vaduganathan M, Bhatt DL. Contemporary parenteral antiplatelet bridging strategies: a single-centre real-world experience at a tertiary care centre. EuroIntervention 2018; 14 (03) e333-e335
    CrossrefPubMedSearch in Google Scholar
  • 13 Kabadi RA, Danelich IM, Entwistle III JW. et al. Use of cangrelor as a bridge to left ventricular assist device implantation in a patient with a recent drug-eluting stent who developed acute tirofiban-related thrombocytopenia. Pharmacotherapy 2019; 39 (04) 521-525
    CrossrefPubMedSearch in Google Scholar
  • 14 Calnan MW, Crawford AN. A case report of cangrelor bridge therapy for a diagnostic bronchoscopy with biopsy. J Pharm Pract 2020; 33 (02) 231-235
    CrossrefPubMedSearch in Google Scholar
  • 15 Cahoon Jr WD, Oswalt AK, Francis KE, Magee LC, Lowe DK. Cangrelor bridge therapy for gastroduodenal biopsy. J Pharm Pract 2017; 30 (02) 270-273
    CrossrefPubMedSearch in Google Scholar
  • 16 Laehn SJ, Feih JT, Saltzberg MT, Garner Rinka JR. Pharmacodynamic-guided cangrelor bridge therapy for orthotopic heart transplant. J Cardiothorac Vasc Anesth 2019; 33 (04) 1054-1058
    CrossrefPubMedSearch in Google Scholar
  • 17 Kristensen SD, Knuuti J, Saraste A. et al; Authors/Task Force Members. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35 (35) 2383-2431
    CrossrefPubMedSearch in Google Scholar
  • 18 Levine GN, Bates ER, Bittl JA. et al. 2016 ACC/ AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68 (10) 1082-1115
    CrossrefPubMedSearch in Google Scholar
  • 19 Neumann FJ, Sousa-Uva M, Ahlsson A. et al; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40 (02) 87-165
    CrossrefPubMedSearch in Google Scholar
  • 20 Rossini R, Musumeci G, Visconti LO. et al; Italian Society of Invasive Cardiology (SICI-GISE), Italian Association of Hospital Cardiologists (ANMCO), Italian Society for Cardiac Surgery (SICCH), Italian Society of Vascular and Endovascular Surgery (SICVE), Italian Association of Hospital Surgeons (ACOI), Italian Society of Surgery (SIC), Italian Society of Anaesthesia and Intensive Care Medicine (SIAARTI), Lombard Society of Surgery (SLC), Italian Society of Maxillofacial Surgery (SICMF), Italian Society of Reconstructive Plastic Surgery and Aesthetics (SICPRE), Italian Society of Thoracic Surgeons (SICT), Italian Society of Urology (SIU), Italian Society of Orthopaedics and Traumatology (SIOT), Italian Society of Periodontology (SIdP), Italian Federation of Scientific Societies of Digestive System Diseases Lombardia (FISMAD), Association of Obstetricians Gynaecologists Italian Hospital Lombardia (AOGOI), Society of Ophthalmology Lombardia (SOL). Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies. EuroIntervention 2014; 10 (01) 38-46
    CrossrefPubMedSearch in Google Scholar
  • 21 Rossini R, Tarantini G, Musumeci G. et al; Italian Society of Interventional Cardiology (SICI-GISE), Italian Society for the Study of Haemostasis and Thrombosis (SISET), Italian Society of Anesthesia and Intensive Care Medicine (SIAARTI), Italian Society of Surgery (SIC), Italian Society for Cardiac Surgery (SICCH), Italian Society of Vascular and Endovascular Surgery (SICVE), Italian Society of Urology (SIU), Italian Orthopaedic Society (SIOT), Italian Society of Thoracic Surgeons (SICT), Italian Federation of Scientific Societies of Digestive System Diseases (FISMAD), Italian Society of Digestive Endoscopy (SIED), Italian Association of Hospital Gastroenterology and Digestive Endoscopy (AIGO), Italian Association of Gastroenterology and Digestive Endoscopy (SIGE), Italian Society of Maxillofacial Surgery (SICMF), Italian Society of Reconstructive Plastic Surgery and Aesthetics (SICPRE), Italian Society of Gynecology and Obstetrics (SIGO), Italian Society of Neurosurgery (SINch), Italian Association of Hospital Pulmonologist (AIPO), Italian Society of Periodontology (SIdP), Italian Society of Ophthalmology (SOI), Italian Association of Hospital Otorhinolaryngologist (AOOI), Italian Association of Hospital Surgeons (ACOI), Association of Obstetricians Gynecologists Italian Hospital (AOGOI). A multidisciplinary approach on the perioperative antithrombotic management of patients with coronary stents undergoing surgery: surgery after stenting 2. JACC Cardiovasc Interv 2018; 11 (05) 417-434
    CrossrefPubMedSearch in Google Scholar
  • 22 Angiolillo DJ, Rollini F, Storey RF. et al. International expert consensus on switching platelet P2Y12 receptor-inhibiting therapies. Circulation 2017; 136 (20) 1955-1975
    CrossrefPubMedSearch in Google Scholar
  • 23 Franchi F, Rollini F, Muñiz-Lozano A, Cho JR, Angiolillo DJ. Cangrelor: a review on pharmacology and clinical trial development. Expert Rev Cardiovasc Ther 2013; 11 (10) 1279-1291
    CrossrefPubMedSearch in Google Scholar
  • 24 Cutlip DE, Windecker S, Mehran R. et al; Academic Research Consortium. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 2007; 115 (17) 2344-2351
    CrossrefPubMedSearch in Google Scholar
  • 25 Vaduganathan M, Harrington RA, Stone GW. et al. Short- and long-term mortality following bleeding events in patients undergoing percutaneous coronary intervention: insights from four validated bleeding scales in the CHAMPION trials. EuroIntervention 2018; 13 (15) e1841-e1849
    CrossrefPubMedSearch in Google Scholar
  • 26 Conte MS, Bradbury AW, Kolh P. et al; GVG Writing Group for the Joint Guidelines of the Society for Vascular Surgery (SVS), European Society for Vascular Surgery (ESVS), and World Federation of Vascular Societies (WFVS). Global vascular guidelines on the management of chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg 2019; 58 (1S): S1-109.e33
    CrossrefPubMedSearch in Google Scholar
  • 27 Begic D, Mujicic E, Coric J, Zec SL, Zunic L. Analysis of the blood consumption for surgical programs. Med Arh 2016; 70 (04) 248-251
    CrossrefPubMedSearch in Google Scholar
  • 28 Savonitto S, Caracciolo M, Cattaneo M, DE Servi S. Management of patients with recently implanted coronary stents on dual antiplatelet therapy who need to undergo major surgery. J Thromb Haemost 2011; 9 (11) 2133-2142
    CrossrefPubMedSearch in Google Scholar
  • 29 Albaladejo P, Marret E, Samama CM. et al. Non-cardiac surgery in patients with coronary stents: the RECO study. Heart 2011; 97 (19) 1566-1572
    CrossrefPubMedSearch in Google Scholar
  • 30 Egholm G, Kristensen SD, Thim T. et al. Risk associated with surgery within 12 months after coronary drug-eluting stent implantation. J Am Coll Cardiol 2016; 68 (24) 2622-2632
    CrossrefPubMedSearch in Google Scholar
  • 31 van Kuijk JP, Flu WJ, Schouten O. et al. Timing of noncardiac surgery after coronary artery stenting with bare metal or drug-eluting stents. Am J Cardiol 2009; 104 (09) 1229-1234
    CrossrefPubMedSearch in Google Scholar
  • 32 Brilakis ES, Banerjee S, Berger PB. Perioperative management of patients with coronary stents. J Am Coll Cardiol 2007; 49 (22) 2145-2150
    CrossrefPubMedSearch in Google Scholar
  • 33 Dargham BB, Baskar A, Tejani I. et al. Intravenous antiplatelet therapy bridging in patients undergoing cardiac or non-cardiac surgery following percutaneous coronary intervention. Cardiovasc Revasc Med 2019; 20 (09) 805-811
    CrossrefPubMedSearch in Google Scholar
  • 34 Muñiz-Lozano A, Rollini F, Franchi F, Angiolillo DJ. Update on platelet glycoprotein IIb/IIIa inhibitors: recommendations for clinical practice. Ther Adv Cardiovasc Dis 2013; 7 (04) 197-213
    CrossrefPubMedSearch in Google Scholar
  • 35 Groves EM, Bhatt DL, Steg PG. et al. Incidence, predictors, and outcomes of acquired thrombocytopenia after percutaneous coronary intervention: a pooled, patient-level analysis of the CHAMPION Trials (cangrelor versus standard therapy to achieve optimal management of platelet inhibition). Circ Cardiovasc Interv 2018; 11 (04) e005635
    CrossrefPubMedSearch in Google Scholar
  • 36 De Servi S, Morici N, Boschetti E. et al. Bridge therapy or standard treatment for urgent surgery after coronary stent implantation: analysis of 314 patients. Vascul Pharmacol 2016; 80: 85-90
    CrossrefPubMedSearch in Google Scholar
  • 37 Morici N, Moja L, Rosato V. et al. Bridge with intravenous antiplatelet therapy during temporary withdrawal of oral agents for surgical procedures: a systematic review. Intern Emerg Med 2014; 9 (02) 225-235
    CrossrefPubMedSearch in Google Scholar
  • 38 Chew DP, Junbo G, Parsonage W. et al; Perceived Risk of Ischemic and Bleeding Events in Acute Coronary Syndrome Patients (PREDICT) Study Investigators. Perceived risk of ischemic and bleeding events in acute coronary syndromes. Circ Cardiovasc Qual Outcomes 2013; 6 (03) 299-308
    CrossrefPubMedSearch in Google Scholar
  • 39 Estcourt LJ, Birchall J, Allard S. et al; British Committee for Standards in Haematology. Guidelines for the use of platelet transfusions. Br J Haematol 2017; 176 (03) 365-394
    CrossrefPubMedSearch in Google Scholar
  • 40 Makris M, Van Veen JJ, Tait CR, Mumford AD, Laffan M. British Committee for Standards in Haematology. Guideline on the management of bleeding in patients on antithrombotic agents. Br J Haematol 2013; 160 (01) 35-46
    CrossrefPubMedSearch in Google Scholar
  • 41 Bhattad VB, Gaddam S, Lassiter MA. et al. Intravenous cangrelor as a peri-procedural bridge with applied uses in ischemic events. Ann Transl Med 2019; 7 (17) 408
    CrossrefPubMedSearch in Google Scholar