ATLANTIC: In-Ambulance vs. In-Cath Lab Administration of Ticagrelor in STEMI Patients Transferred For Primary PCI

Pre-hospital administration of ticagrelor in patients with acute ST-segment elevation myocardial infarction (STEMI) does not improve pre-percutaneous coronary intervention (PCI) coronary reperfusion, but it does appear safe and may prevent post-procedural acute stent thrombosis, according to results from the ATLANTIC trial presented Sept. 1 as part of ESC Congress 2014 and simultaneously published in the New England Journal of Medicine.

The international, multi-center trial was based on 1,862 patients with ongoing STEMI of less than six hours duration who received ticagrelor treatment either in the ambulance or in the catheterization lab. Overall, the median time from randomization to angiography was 48 minutes and the median time difference between the two treatment strategies was 31 minutes. According to study investigators, the proportion of patients who did not have a 70 percent or greater resolution of ST-segment elevation before PCI and who did not have thrombolysis in myocardial infarction flow grade 3 in the infarct-related artery at initial angiography did not vary significantly between the two groups. The rates of major adverse cardiovascular events and of major bleeding also did not vary significantly.

However, the rates of definite stent thrombosis were lower in the pre-hospital group than the in-hospital group. "The observed preventive benefit is consistent with pharmacodynamics and ECG findings suggesting that the maximal effort of pre-hospital administration of ticagrelor occurs after the end of the procedure," the investigators said.

Investigators did note limitations to the study based on the small sample size and the short intervals between administration of ticagrelor and reperfusion. "The time to PCI in our study was extremely short in both groups indicating excellent practice," they said, "but this may have blunted the drug effect and may not reflect clinical practice."

Keywords: Myocardial Infarction, Thrombosis, Catheterization, Hospital Administration, Electrocardiography, Angioplasty, Balloon, Coronary, Purinergic P2Y Receptor Antagonists, Myocardial Reperfusion, Stents

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