Impact of Cangrelor on Outcomes After Percutaneous Coronary Intervention for Acute Coronary Syndrome in High Bleeding Risk Patients

The safety and efficacy of cangrelor during percutaneous coronary intervention (PCI) in high-bleeding-risk (HBR) acute coronary syndrome (ACS) patients remain unclear. We evaluated the impact of cangrelor on outcomes after PCI in HBR ACS patients. ACS patients with data available to identify HBR status (per 2019 Academic Research Consortium criteria) who underwent PCI at our institution between 2018-2023 (n=2509) were screened. Those presenting with cardiogenic shock or requiring thrombectomy or glycoprotein 2b/3a inhibitors during PCI were excluded (n=201) and 1007 were categorized as HBR. In-hospital composite ischemic events (inpatient mortality, target vessel revascularization, stent thrombosis, and ischemic stroke) and major bleeding (intracranial hemorrhage, blood transfusion for hemoglobin drop >3g/dL) were compared between cangrelor and non-cangrelor groups. The cohort had a mean age of 71.8 years and 54.5% were male. Cangrelor group had fewer chronic comorbidities but presented with higher acuity, with increased rates of ST-elevation (STE-ACS) (33.4% vs 6%, p<0.001), greater new-onset congestive heart failure (CHF) (10.3% vs 3.5%, p<0.001), intra-aortic balloon pump use (11.9% vs 4.4%, p<0.001), and new acute kidney injury (AKI) (10.9% vs 5.7%, p=0.003). Multivariate analysis adjusting for age, STE-ACS, new onset CHF, and AKI showed similar ischemic OR(CI): 1.52(0.68-3.27), p=0.30 and major bleeding OR(CI): 1.65(0.92-2.93), p=0.09 outcomes among cangrelor and non-cangrelor patients. In conclusion, cangrelor use in HBR ACS patients undergoing PCI was not associated with improved outcomes versus oral P2Y12 inhibitors, although similar event rates despite higher acuity in the cangrelor group may suggest potential benefit in select patients without added bleeding risk.