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

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
Consulting Fees/Honoraria
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Company Names

3. Gary L. Schaer MD Disclosure: Consultant; Advisory Board
Consultant; Advisory Board
The Medicines Company
AstraZeneca

4. 55 yo man with chest pain

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

6. Right Coronary Angiography

7. 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 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).

8. 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

9. 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

10. Initial PTCA of 100% RCA

11. Post PTCA Result

12. Post DES Deployment

13. 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

14. Left coronary angiography

15. Left coronary angiography

16. Left coronary angiography

17. 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

18. 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

19. 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”

20. EKG

21. 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

22. Coronary Angiography

23. 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 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).

24. 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

25. Stent Position at LAD Ostium

26. Post Stent Deployment

27. 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

28. 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