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Am Heart J. 2018 Feb;196:56-64. doi: 10.1016/j.ahj.2017.10.021. Epub 2017 Nov 4.

Duration of ischemia and treatment effects of pre- versus in-hospital ticagrelor in patients with ST-segment elevation myocardial infarction: Insights from the ATLANTIC study.

Author information

1
Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada.
2
Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada; Canadian Heart Research Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Canada. Electronic address: goodmans@smh.ca.
3
Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada.
4
ACTION Study Group, Unité de Recherche Clinique, Hôpital Lariboisière (AP-HP), Paris, France.
5
Cardiovascular and Neurological Department, Azienda Ospedaliera Arezzo, Arezzo, Italy.
6
Heart Disease Institute, Hospital Universitario de Bellvitge, University of Barcelona, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
7
Centre Hospito-universitaire Frantz Fanon, Blida, Algeria.
8
Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
9
3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, and Sigmund Freud Private University, Medical School, Vienna, Austria.
10
Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
11
SAMU 93 Hôpital Avicenne, Bobigny, France.
12
Department of Cardiology, The Hearth Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
13
Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
14
Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
15
Department of Cardiology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands.
16
Klinikum Ludwigshafen and Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.
17
ACTION Study Group, Unité de Recherche Clinique, Hôpital Lariboisière (AP-HP), Paris, France; Unité de Recherche Clinique Lariboisière Saint-Louis Hôpital Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France.
18
Kerckhoff Klinik, Bad Nauheim, Germany.
19
AstraZeneca, La Défense, France.
20
AstraZeneca, Cambridge, United Kingdom.
21
Maastricht Hart+Vaat Centrum/MUMC, Maastricht, The Netherlands.
22
Sorbonne Université Paris 6, ACTION Study Group, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France.

Abstract

BACKGROUND:

Among patients with STEMI in the ATLANTIC study, pre-hospital administration of ticagrelor improved post-PCI ST-segment resolution and 30-day stent thrombosis. We investigated whether this clinical benefit with pre-hospital ticagrelor differs by ischemic duration.

METHODS:

In a post hoc analysis we compared absence of ST-segment resolution post-PCI and stent thrombosis at 30 days between randomized treatment groups (pre- versus in-hospital ticagrelor) stratified by symptom onset to first medical contact (FMC) duration [≤1 hour (n = 773), >1 to ≤3 hours (n = 772), and >3 hours (n = 311)], examining the interaction between randomized treatment strategy and duration of symptom onset to FMC for each outcome.

RESULTS:

Patients presenting later after symptom onset were older, more likely to be female, and have higher baseline risk. Patients with symptom onset to FMC >3 hours had the greatest improvement in post-PCI ST-segment elevation resolution with pre- versus in-hospital ticagrelor (absolute risk difference: ≤1 hour, 2.9% vs. >1 to ≤3 hours, 3.6% vs. >3 hours, 12.2%; adjusted p for interaction = 0.13), while patients with shorter duration of ischemia had greater improvement in stent thrombosis at 30 days with pre- versus in-hospital ticagrelor (absolute risk difference: ≤1 hour, 1.3% vs. >1 hour to ≤3 hours, 0.7% vs. >3 hours, 0.4%; adjusted p for interaction = 0.55). Symptom onset to active ticagrelor administration was independently associated with stent thrombosis at 30 days (adjusted OR 1.89 per 100 minute delay, 95%CI 1.20-2.97, P < .01), but not post-PCI ST-segment resolution (P = .41).

CONCLUSIONS:

The effect of pre-hospital ticagrelor to reduce stent thrombosis was most evident when given early within 3 hours after symptom onset, with delay in ticagrelor administration after symptom onset associated with higher rate of stent thrombosis. These findings re-emphasize the need for early ticagrelor administration in primary PCI treated STEMI patients.

TRIAL REGISTRATION:

ClinicalTrials.gov NCT01347580.

PMID:
29421015
DOI:
10.1016/j.ahj.2017.10.021
[Indexed for MEDLINE]

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