Oral P2Y12 inhibitors only versus cangrelor in critically ill patients requiring percutaneous coronary interventions supported by microaxial flow pumps.

Background Oral P2Y12 inhibitors (P2Y12i) may have reduced efficacy in critically ill patients undergoing Impella-supported PCI. The intravenous P2Y12i cangrelor offers rapid and reversible platelet inhibition, but its role in this setting remains unclear. Objective Comparison of outcomes in patients undergoing Impella-supported PCI receiving oral P2Y12i only versus loading with cangrelor.Methods We analyzed consecutive patients managed at a Swiss tertiary cardiology facility who underwent Impella-supported PCI. Patients received either (1) oral P2Y12i or (2) cangrelor followed by oral P2Y12i. Periprocedural major bleeding (BARC ≥ 3) within 48 h, in-hospital major adverse cardiovascular events (MACE) and 6-month MACE were analyzed. Results Among 295 patients, 201 received oral P2Y12i and 94 received cangrelor. Patients in the oral P2Y12i group were less likely to present with STEMI (55.7% versus 67.0%) or cardiogenic shock (55.2% versus 72.3%), whereas high-risk protected PCI was more frequent (17.9% versus 6.4%) compared to cangrelor group. No significant differences were observed in major bleeding, in-hospital MACE and 6-month MACE. Major bleeding was numerically lower in the oral P2Y12i group (26.4% versus 33.0%, p = 0.2). Early stent thrombosis rates were relatively low and not significantly different (1.0% versus 2.1%, p = 0.6). Presentation with cardiogenic shock was associated with a higher risk for post-PCI major bleeding (OR 7.09, 95%CI 2.97-18.49) and 6-month MACE (HR 2.01, 95% CI 1.01-3.97). Conclusion In Impella-supported PCI, cangrelor was associated with no statistically significant differences in outcomes compared to oral P2Y12i, with consistent results after adjustment. Given the observational design, these findings require confirmation in randomized trials.