Comparative outcomes of IV Cangrelor and oral P2Y12 inhibitors in ACS patients undergoing revasvularisation: A systematic review and meta-analysis

Abstract: Background: Cangrelor is a direct-acting intravenous P2Y12 inhibitor with a rapid onset of action and a short, predictable offset that allows platelet function to return to baseline within an hour of discontinuation. Given these advantages, cangrelor has been increasingly used to decrease the risk of perioperative and procedural complications in acute coronary syndrome (ACS) patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Objectives: To compare the ischemic and safety outcomes between IV cangrelor and oral P2Y12 inhibitors in patients of ACS undergoing revascularisation. Methods: A systematic search was conducted of PubMed/MEDLINE, Cochrane Library, ScienceDirect, and ClinicalTrials.gov was conducted from inception to 2024 for randomized clinical trials or observational cohorts comparing IV cangrelor with oral P2Y12 inhibitors among ACS patients undergoing revascularisation. Data was independently reviewed and screened by two reviewers and pooled using a random effects meta-analysis model. Results: Four studies including 25,881 participants were analyzed. Compared to oral P2Y12 inhibitors, cangrelor demonstrated significantly lower risk of stent thrombosis Across all included studies, patient demographics and baseline risk profiles were similar. Cangrelor was associated with a significantly lower incidence of stent thrombosis (OR 0.56; 95% CI 0.40–0.80; p=0.004) and higher bleeding risk (OR 1.46; 95% CI 1.22–1.74; p<0.0001). Conclusion: IV cangrelor reduces the risk of stent thrombosis without increasing the risk of other major adverse cardiovascular events, but at the cost of increased major bleeding. Its use may be most appropriate when rapid, reversible platelet inhibition is required, warranting careful clinical judgment.