Prehospital administration of ticagrelor did not improve either short- or long-term outcomes for patients with ST-elevation myocardial infarction over the standard in-hospital administration of the drug.
Patients who received ticagrelor in the field had virtually identical rates of 70% or greater post–percutaneous coronary intervention resolution and post-PCI cardiovascular events as those who got the drug after hospital admission, Dr. Gilles Montalescot and his colleagues reported at the online at the annual congress of the European Society of Cardiology. The results were simultaneously published online (N. Engl. J. Med. 2014 Sept. 1; [doi:10.1056/NEJMoa1407024]).
Dr. Gilles Montalescot
The phase IV ATLANTIC (Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST Elevation Myocardial Infarction to Open the Coronary artery) trial, conducted in 112 PCI centers among 13 countries, randomized 1,862 patients with ongoing STEMI of less than 6 hours’ duration to either a 180-mg loading dose of ticagrelor before hospital transfer, or to the same protocol in the PCI lab. All patients then received an ongoing regimen of 90 mg twice daily for 30 days, with the recommendation that this be continued for 12 months. Some patients also received glycoprotein IIB/IIIa inhibitors in the ambulance, but this was delivered at the physicians’ discretion.
In addition to STEMI resolution, primary endpoint included the proportion of patients who didn’t meet TIMI flow grade 3 in the infarcted artery before PCI. Secondary endpoints were a composite measure of death, MI, stent thrombosis, or urgent revascularization at 30 days; thrombotic bailout with glycoprotein inhibition, TIMI flow grade 3 at the end of the procedure, and complete STEMI resolution at by 60 minutes after PCI, reported Dr. Montalescot, director of cardiac care at the Pitié-Salpêtrière Hospital in Paris, and his coauthors.
Safety endpoints included major bleeding after PCI.
The patients were a mean of 61 years old. About 19% had a body mass index of 30 kg/m2 or higher. For 75%, the first point of care was in the ambulance. About 30% had glycoprotein inhibition before PCI.
The rates of a STEMI resolution of at least 70% were almost identical in the prehospital and in-hospital groups (86.8% and 87.6%, respectively), as was the absence of TIMI flow grade 3 in the infarcted artery by the time of PCI (82.6% and 83.1%). Likewise, a similar proportion of patients met either one or both secondary endpoints (49.6% and 52.8%).
While there was no significant between-group difference in the composite endpoint, stent thrombosis at 24 hours after PCI was lower in the prehospital group than in the in-hospital group (0% and 8%, respectively), and also at 30 days afterward (0.2% and 1.2%).
In all, 49 patients died, 30 in the prehospital group and 19 in the in-hospital group – not a significant difference (3.3% vs. 2%). The most common causes were cardiogenic shock, cardiac arrest, mechanical complications, and heart failure.
Major bleeding rates within the first 48 hours were low and similar (1.8% vs.1.6%); 30-day rates were identical (1.2% vs. 1.2%).
"Our study shows that there is no downside to earlier administration of ticagrelor, and it reduces the risk of post-procedure stent thrombosis. ... It is also a more practical time point for administration of the drug than in the catheterisation laboratory, where considerable staff and technical demands already exist," Dr. Montalescot said in a statement.
AstraZeneca sponsored the study. Dr. Montalescot reported receiving grants from the company and other pharmaceutical companies. He also reported consulting fees from 25 different pharmaceutical companies and study groups, including the ATLANTIC study.
The coauthors also reported numerous financial relationships with pharmaceutical companies, including AstraZeneca.
On Twitter @alz_gal