Written by Katrina Mountford, Medical Editor.
19th March 2018
Patients with non‐ST‐segment elevation (NSTE) acute coronary syndrome (ACS) undergoing early percutaneous intervention (PCI) who exhibit increased platelet reactivity, defined as high-on treatment platelet rapacity (HPR), are at increased risk of thrombotic events or stent thrombosis. A recent study showed that HPR remained high following PCI in patients with unstable angina loaded with ticagrelor (a potent P2Y12 inhibitor) just before PCI.1 These data indicate that even potent P2Y12 inhibitors do not achieve maximal platelet inhibition during PCI where platelets are highly reactive. Another recent study showed that the absorption of crushed ticagrelor was faster than the integral ticagrelor tablet and HPR was significantly lower with crushed ticagrelor in patients with unstable angina.2 However, the rates of HPR and periprocedural myocardial infarction (MI) in patients treated with crushed ticagrelor vs. eptifibatide bolus (a glycoprotein IIb-IIIa inhibitor (GPI) + clopidogrel have not been investigated.
Dr Leesar presented a study that aimed to test the hypothesis that HPR and periprocedural MI will be significantly lower in patients with unstable angina randomised to eptifibatide bolus + clopidogrel vs. crushed ticagrelor. Of 250 screened patients, 100 patients were randomised to crushed ticagrelor 180 mg (n=50) or eptifibatide bolus + clopidogrel 600 mg (n=50). Baseline patient and procedural characteristics did not differ significantly between groups. Results showed that the rates of HPR were significantly lower with eptifibatide bolus + clopidogrel at 30 min and 2 h as compared with crushed ticagrelor. In addition, the inhibition of platelet aggregation was significantly higher at 30 min, 2h and 4h with eptifibatide bolus + clopidogrel compared with crushed ticagrelor. The incidence of periprocedural MI was significantly higher in the crushed ticagrelor group vs. eptifibatide + clopidogrel group. At 24h, the rate of HPR was not significantly different between the groups. The dose of heparin and activated clotting time (ACT) levels were significantly lower with eptifibatide bolus + clopidogrel compared with crushed ticagrelor.
These findings might improve the safety of GPI use while significantly inhibiting platelet reactivity. A large randomised trial is warranted to assess the safety and efficacy of eptifibatide bolus + clopidogrel vs. crushed ticagrelor.
1. Angiolillo DJ, Franchi F, Waksman R, et al., Effects of Ticagrelor Versus Clopidogrel in Troponin-Negative Patients With Low-Risk ACS Undergoing Ad Hoc PCI, J Am Coll Cardiol, 2016;67:603-13.
2. Niezgoda P, Sikora J, Baranska M, et al., Crushed sublingual versus oral ticagrelor administration strategies in patients with unstable angina. A pharmacokinetic/pharmacodynamic study, Thromb Haemost, 2017;117:718-26.