Cangrelor Case Presentations Gary L. Schaer, MD FACC, FAHA, FSCAI Professor of Medicine (Interventional Cardiology) Director, Cardiology Research Rush University Medical Center Chicago IL

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55 yo man with chest pain

Pre-angiography Troponin <0.01 Glucose 182 mg/dL; HbA1C 6.7% STEMI page activated Aspirin 325 mg po No preloading with P2Y12 inhibitor

Right Coronary Angiography

EKG ACS Management Pathway STEMI Pathway NSTE-ACS Pathway Patient presents with symptoms of ACS EKG No ST-elevation ST-elevation ACS Management Pathway NSTE-ACS Pathway Aspirin 325 mg po or chewed + UFH (not LMWH) DO NOT GIVE TICAGRELOR OR CLOPIDOGREL BEFORE CORONARY ANGIOGRAPHY STEMI Pathway Aspirin 325 mg po or chewed Emergency transfer to cath lab DO NOT GIVE TICAGRELOR OR CLOPIDOGREL BEFORE CORONARY ANGIOGRAPHY Ischemia-Guided Strategy (low risk) Low risk TIMI score (0-1), GRACE (<109) Low risk trop neg female patients Patient or clinician preference in absence of high-risk features Stress test (if + => Cath) Early Invasive Strategy (intermediate to high risk) DO NOT GIVE TICAGRELOR OR CLOPIDOGREL BEFORE CORONARY ANGIOGRAPHY Unfractionated heparin and anti-ischemic therapy Immediate Invasive Cath <2h Refractory or recurrent angina despite Med Rx Severe HF, unstable hemodynamics, malignant arrhythmias Early Invasive Cath <24h No “immediate invasive” features GRACE score >140 Temporal change in Trop New ST-seg depression Delayed Invasive Cath 25-72hs GFR <60 mL/min/1.73m2 EF <40% Early post-MI angina PCI within 6mo or CABG GRACE 109-140 or TIMI >2 Coronary Angiography -> PCI At start of PCI consider cangrelor (bolus + 2hr infusion) + anticoagulant (bivalirudin or UFH) Transition to oral P2Y12 therapy (if surgery not planned prior to discharge): ticagrelor 180 (begin during cangrelor infusion), or clopidogrel 600 mg (must begin immediately after cangrelor d/c).

PCI of 100% Mid-RCA Femoral access; 4-R Judkins guider Begin cangrelor 30 mcg IV loading dose, 4 mcg/kg/min continuous infusion to continue for 2 hours Begin bivalirudin PTCA 2.5 x 15 balloon IVUS for precise sizing 3.5 x 15mm Resolute DES deployed in mid-RCA IVUS confirms full stent expansion Ticagrelor withheld until completion of diagnostic left coronary angiogram

PCI of 100% Mid-RCA Femoral access; 4-R Judkins guider Begin cangrelor 30 mcg IV loading dose, 4 mcg/kg/min continuous infusion to continue for 2 hours Begin bivalirudin

Initial PTCA of 100% RCA

Post PTCA Result

Post DES Deployment

PCI of 100% Mid-RCA PTCA 2.5 x 15 balloon IVUS for precise sizing 3.5 x 15mm Resolute DES deployed in mid-RCA IVUS confirms full stent expansion Ticagrelor withheld until completion of diagnostic left coronary angiogram

Left coronary angiography

Left coronary angiography

Left coronary angiography

Left coronary angiography 90% proximal LAD with involvement of a bifurcating diagonal branch with a 70% at origin; LAD diffusely diseased with a large territory (wraps around apex) 70% ostial OM3, 90% distal circumflex (TIMI-2 flow) Films reviewed with heart team; decision made to proceed with CABG (plan for LIMA to LAD, SVG to diagonal, SVG to OM3 sequential to OM4) No P2Y12 inhibitor given Bivalirudin and cangrelor discontinued in cath lab Patient transported to OR for urgent CABG

Post CABG CABG surgery completed with no bleeding problems The patient was loaded with 180 mg of ticagrelor after transfer to the surgical ICU Additional medication started: atorvastatin 80mg po, lisinopril 10mg po, and metformin Ticagrelor 90 bid, aspirin 81 mg continued post-op (plan to continue for 4 years post-MI) Patient discharged on post-op day 5 to follow-up with cardiac surgeon and interventional cardiologist in 1-2 weeks Cardiac rehab recommended

46 yo Man with Chest Pain No prior medical history Presents to Rush ED with intermittent “burning” substernal chest pain and SOB for 2-3 days. Smokes 2 packs/day; construction worker No family history of CAD and no other known medical problems Has not seen a doctor in “many years”

EKG

Pre-angiography Troponin 0.14 (normal <0.10) Interventional service consulted by ED – urgent coronary angiogram recommended Aspirin 325 mg po Unfractionated heparin IV No preloading with P2Y12 inhibitor

Coronary Angiography

EKG ACS Management Pathway STEMI Pathway NSTE-ACS Pathway Patient presents with symptoms of ACS EKG No ST-elevation ST-elevation ACS Management Pathway NSTE-ACS Pathway Aspirin 325 mg po or chewed + UFH (not LMWH) DO NOT GIVE TICAGRELOR OR CLOPIDOGREL BEFORE CORONARY ANGIOGRAPHY STEMI Pathway Aspirin 325 mg po or chewed Emergency transfer to cath lab DO NOT GIVE TICAGRELOR OR CLOPIDOGREL BEFORE CORONARY ANGIOGRAPHY Ischemia-Guided Strategy (low risk) Low risk TIMI score (0-1), GRACE (<109) Low risk trop neg female patients Patient or clinician preference in absence of high-risk features Stress test (if + => Cath) Early Invasive Strategy (intermediate to high risk) DO NOT GIVE TICAGRELOR OR CLOPIDOGREL BEFORE CORONARY ANGIOGRAPHY Unfractionated heparin and anti-ischemic therapy Immediate Invasive Cath <2h Refractory or recurrent angina despite Med Rx Severe HF, unstable hemodynamics, malignant arrhythmias Early Invasive Cath <24h No “immediate invasive” features GRACE score >140 Temporal change in Trop New ST-seg depression Delayed Invasive Cath 25-72hs GFR <60 mL/min/1.73m2 EF <40% Early post-MI angina PCI within 6mo or CABG GRACE 109-140 or TIMI >2 Coronary Angiography -> PCI At start of PCI consider cangrelor (bolus + 2hr infusion) + anticoagulant (bivalirudin or UFH) Transition to oral P2Y12 therapy (if surgery not planned prior to discharge): ticagrelor 180 (begin during cangrelor infusion), or clopidogrel 600 mg (must begin immediately after cangrelor d/c).

PCI of Ostial LAD Femoral access - 90% ostial LAD – no other significant CAD Begin cangrelor 30 mcg IV loading dose, 4 mcg/kg/min continuous infusion to continue for 2 hours Begin bivalirudin 3.5 L-EBU guide; PTCA 2.5 x 15 balloon IVUS for precise sizing 4.0 x 15mm Xience DES deployed at LAD ostium IVUS to confirm full stent expansion

Stent Position at LAD Ostium

Post Stent Deployment

Post-PCI Load with 180 mg of ticagrelor po D/C bivalirudin Continue cangrelor until infusion complete (2 hours from start of infusion) Transfer to CCU Discharge in AM on ticagrelor + aspirin 81mg (plan for DAPT to continue for at least 1 year), atorvastatin 80mg Smoking cessation counseling Cardiac rehab recommended Follow-up in 1-2 weeks with interventional cardiologist

55 yo Man with Chest Pain 55 yo Asian man presents with “severe” left precordial chest pain that came on while running to catch a train Chest pain associated with shortness of breath, nausea and diaphoresis 911 called and patient brought to Rush ED; symptoms improved with nitro SL and morphine Past medical history Diabetes mellitus type 2 – “diet controlled” Hypertension – no meds Hyperlipidemia – no meds Non-smoker