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ATLANTIC: Pre-hospital ticagrelor did not benefit reperfusion but lowered stent thrombosis in STEMI
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BARCELONA, Spain — Although safe, pre-hospital administration of ticagrelor did not improve pre-PCI coronary reperfusion in patients with acute STEMI when compared with in-hospital administration of the drug, according to data presented here at ESC Congress.
“[Pre-hospital ticagrelor administration] may, however, reduce the risk of stent thrombosis after PCI,” Gilles Montalescot, MD, PhD, of the Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, said at a press conference.
Montalescot presented data from the ATLANTIC trial showing no difference between pre-hospital and in-hospital administration of ticagrelor (Brilinta, AstraZeneca) in the two co-primary endpoints: absence of ST-segment elevation resolution ≥70% before PCI (pre-hospital, 86.8% vs. in-hospital, 87.6%; OR=0.93; 95% CI, 0.69-1.25; P=.63); and absence of TIMI flow grade 3 in infarct-related arteries at initial angiography (pre-hospital, 82.6% vs. in-hospital, 83.1%; OR=0.97; 95% CI, 0.75-1.25; P=.82).
Gilles Montalescot
Secondary endpoint analysis showed that the absence of ST-segment elevation resolution ≥70% after PCI was 42.5% in the pre-hospital group and 47.5% in the in-hospital group (OR=0.82; 95% CI, 0.66-1.004; P=.05), and absence of TIMI flow grade 3 in infarct-related arteries after PCI was 17.8% in the pre-hospital cohort and 19.6% in the in-hospital cohort (OR=0.88; 95% CI, 0.68-1.14; P=.34).
Additionally, rates of non-CABG-related bleeding events within 48 hours and after 48 hours and up to 30 days did not differ between groups, nor did rates of MACE. However, definite stent thrombosis at 30 days after index PCI was lower in the pre-hospital group (0.2% vs. 1.2%; OR=0.19; 95% CI, 0.04-0.86; P=.02).
In the PLATO trial, in-hospital ticagrelor significantly reduced stent thrombosis compared with clopidogrel, Montalescot said. He added that ATLANTIC investigators “observed the same rate of stent thombosis in the group receiving in-hospital ticagrelor, but there was a highly significant reduction with pre-hospital administration of ticagrelor.”
For the international, randomized, multicenter, double blind ATLANTIC trial, Montalescot and colleagues enrolled 1,862 patients with ongoing STEMI of less than 6 hours of duration. They compared pre-hospital (in the ambulance; n=906) and in-hospital (in the cath lab; n=952) administration of the direct-acting P2Y12 receptor inhibitor ticagrelor. Patients were randomly assigned to angiography at a median of 48 minutes, whereas the median time difference between the two treatment strategies was 31 minutes. – by Brian Ellis
For more information:
Montalescot G. Hot line: Myocardial infarction. Presented at: the European Society of Cardiology Congress; Aug. 30-Sept. 3, 2014; Barcelona, Spain.
Montalescot G. N Engl J Med. 2014;doi:10.1056/nejmao1407024.
Disclosure: Montalescot reports receiving grant support from Abbott Vascular, Daiichi Sankyo, Nonospheres and Stentys; and grant support and personal fees from Accumetrics, AstraZeneca, Bayer, Biotronik, Boehringer Ingelheim, Bristol-Myers Squibb, CFR, Eli Lilly, Europa, GLG, Iroko Cardio International, Lead-Up, Luminex, McKinsey, Medtronic, Menarini, Pfizer, Remedica, Sanofi Aventis, Servier and The Medicines Company.
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W. Douglas Weaver, MD
Although the ATLANTIC study did not find a difference with the co-primary endpoints, the investigators did make one interesting observation: The rate of stent thrombosis was lower in patients who received ticagrelor early, in the pre-hospital setting, compared with those who received it in the cath lab. The study was not large enough to confirm whether this will have clinical importance, but we do know that stent thrombosis is a major problem that potentially leads to another MI or death, so this is an important observation. The investigators also showed that pre-hospital administration of ticagrelor is safe and doesn’t result in any extra bleeding or complications.
I think the first take away from this study is that if you can give the drug sooner, you probably should. Second, I wouldn’t be surprised if they do a larger study to show that earlier administration of ticagrelor (before the cath lab) could make a big clinical difference.
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