Heart Attack: Antiplatelet Use in Ambulance May Decrease Stent Thrombosis

Gilles Montalescot M.D., Ph.D. Professor of Cardiology University of Paris VI; Director, Cardiac Care Unit Institute of Cardiology, Pitié-Salpêtrière University Hospital Paris, FranceMedicalResearch.com Interview with:
Gilles Montalescot M.D., Ph.D.
Professor of Cardiology
University of Paris VI; Director, Cardiac Care Unit
Institute of Cardiology, Pitié-Salpêtrière University Hospital
Paris, France

Medical Research: What are the main findings of the study?

Dr. Montalescot : Among the 1862 patients with ongoing STEMI who were enrolled in the ATLANTIC study, we found no difference between those randomized to pre-hospital (in-ambulance) ticagrelor 180 mg and those randomized to in-hospital (in-catheterization laboratory) ticagrelor 180 mg in terms of either pre-PCI ST-segment elevation resolution (≥70%) or pre-PCI TIMI 3 flow in the culprit artery, which were the co-primary endpoints. There was also no difference between the groups in terms of major adverse cardiovascular events at 30 days, with the exception that rates of definite stent thrombosis were lower in the pre-hospital ticagrelor group than in the in-hospital group, both in the first 24 hours (0% versus 0.8%, p= 0.008) and at 30 days (0.2% versus 1.2%, p = 0.02). The safety of pre-hospital ticagrelor did not appear to be an issue, since the incidence of non-CABG-related major bleeding was low and similar in both treatment groups, whichever bleeding definition was used (PLATO, TIMI, STEEPLE, GUSTO, ISTH or BARC).

Medical Research: Were any of the findings unexpected?

Dr. Montalescot : Time from randomization to angiography was very short (median 48 minutes), as was the time difference between the two treatment strategies (median 31 minutes). While this reflects very good clinical practice in the study, it is probably not representative of routine practice and may have limited any potential difference in effect between pre- and in-hospital ticagrelor. Another interesting finding was that there was a significant interaction between morphine use and timing of ticagrelor administration (p = 0.005). That is, patients in the pre-hospital ticagrelor group who did not receive morphine were more likely to have ≥70% resolution of ST-segment elevation than those in the in-hospital group. There have been previous reports that co-administration of morphine can delay absorption of oral P2Y12-receptor antagonists,and this may also have had an impact on our results since approximately half of the patients in the study received morphine.

Medical Research: What should clinicians and patients take away from your report?

Dr. Montalescot : In patients presenting with ongoing STEMI, pre-hospital ticagrelor given a short time before PCI appeared to be safe but there was no improvement on in pre-PCI coronary perfusion compared with in-hospital ticagrelor. However, there was an indication that early use of ticagrelor appears to reduce the risk of post-procedural stent thrombosis.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Montalescot : It would be interesting to do a larger study, which may allow for more representative practice in terms of time from diagnosis to angiography. A longer follow-up period may also increase the chances of observing any potential difference in terms of clinical endpoints, since the mortality benefit reported for ticagelor compared with clopidogrel in the PLATO study (18,624 patients) was observed over 12 months of follow-up.

Prehospital Ticagrelor in ST-Segment Elevation Myocardial Infarction

Gilles Montalescot, M.D., Ph.D., Arnoud W. van ‘t Hof, M.D., Ph.D., Frédéric Lapostolle, M.D., Ph.D., Johanne Silvain, M.D., Ph.D., Jens Flensted Lassen, M.D., Ph.D., Leonardo Bolognese, M.D., Warren J. Cantor, M.D., Ángel Cequier, M.D., Ph.D., Mohamed Chettibi, M.D., Ph.D., Shaun G. Goodman, M.D., Christopher J. Hammett, M.B., Ch.B., M.D., Kurt Huber, M.D., Magnus Janzon, M.D., Ph.D., Béla Merkely, M.D., Ph.D., Robert F. Storey, M.D., D.M., Uwe Zeymer, M.D., Olivier Stibbe, M.D., Patrick Ecollan, M.D., Wim M.J.M. Heutz, M.D., Eva Swahn, M.D., Ph.D., Jean-Philippe Collet, M.D., Ph.D., Frank F. Willems, M.D., Ph.D., Caroline Baradat, M.Sc., Muriel Licour, M.Sc., Anne Tsatsaris, M.D., Eric Vicaut, M.D., Ph.D., and Christian W. Hamm, M.D., Ph.D. for the ATLANTIC Investigators

September 1, 2014DOI: 10.1056/NEJMoa1407024


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