• Interventional Techniques & Devices
• Myocardial Infarction
• Cardiology Clinical Trials
• Cardiology

• Interventional Techniques & Devices
• Myocardial Infarction
• Cardiology Clinical Trials

Administration of ticagrelor in-ambulance resulted in reduced rates of stent thrombosis in patients with STEMI undergoing percutaneous coronary intervention (PCI) compared with patients who received ticagrelor in-hospital; however, the co—primary end points were not achieved. Gilles Montalescot, MD, PhD, Centre Hospitalier Universtaire Pitié-Salpêtrière, Paris, France, presented data from the 30-Day Study to Evaluate Efficacy and Safety of Pre-hospital vs In-hospital Initiation of Ticagrelor Therapy in STEMI Patients Planned for PCI [ATLANTIC; NCT01347580].

Although PCI is a lifesaving procedure for patients with STEMI, a feared potential complication is stent thrombosis. Dual antiplatelet therapy, which includes aspirin plus a P2Y12 antagonist inhibitor such as ticagrelor, is recommended to reduce the risk of stent thrombosis. The purpose of the ATLANTIC trial was to determine if the administration of ticagrelor in-ambulance is more effective than in-hospital administration in patients with STEMI.

In the international double-blind trial, 1862 patients with STEMI who were transferred for primary PCI were randomly assigned to receive 180 mg of ticagrelor in-ambulance or in-hospital with matching placebo. After PCI, all patients received ticagrelor (90 mg, BID) for 30 days. The mean time difference of receiving the loading dose of ticagrelor was 31 minutes. The primary end points of the trial were the proportion of patients not achieving ≥ 70% resolution of ST segment elevation prior to PCI or not achieving TIMI flow grade 3 in the suspected artery at the initial angiograph. Additional clinical end points included rates of definite stent thrombosis and major adverse cardiovascular events (MACEs). The primary safety end point was the rate of minor or major bleeding events.

In-ambulance administration of ticagrelor resulted in similar rates of lack of ≥ 70% resolution of ST segment elevation (OR, 0.93; 95% CI, 0.69 to 1.25; P = .63), TIMI flow grade 3 (OR, 0.97; 95% CI, 0.75 to 1.25; P = .82), or MACEs (P = .91) compared with patients who received in-hospital ticagrelor at 30 days. However, treatment with ticagrelor in-ambulance resulted in lower rates of definite stent thrombosis up to 24 hours (P = .0008) and 30 days (OR, 0.19; 95% CI, 0.04 to 0.86; P = .0225) compared with in-hospital treatment. Bleeding rates included minor, major, or life-threatening bleeding related to non—coronary artery bypass grafting for up to 30 days. In addition, rates of overall and serious adverse events were similar between both arms in the study.

Prof Montalescot concluded by stating that, in his opinion, the data from the ATLANTIC trial suggested that in-ambulance administration of ticagrelor was safe and reduced the risk of stent thrombosis in patients with STEMI undergoing PCI. The discussant, Paul Wayne Armstrong, MD, Edmonton, Alberta, Canada, stated that the reduction of stent thrombosis but also the failure to achieve the co—primary end points may be due to chance. In particular, the short time difference of 31 minutes between the pre- or in-hospital administration of ticagrelor may have undermined the results of this study. Therefore, Prof Armstrong suggested that the role of ticagrelor administered in-ambulance is yet to be established.

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