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In-ambulance versus in-cath lab administration of ticagrelor in STEMI patients transferred for primary PCI: the randomized, double-blind ATLANTIC study

ESC Congress report - Hot Line report

Acute Coronary Syndromes (ACS)



By Gilles Montalescot, FESC (Paris, France)
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List of Authors:
Gilles Montalescot, on behalf of the ATLANTIC Investigators

Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France


The ATLANTIC study (NCT01347580) was designed to assess the effects of pre-hospital (in-ambulance) versus in-hospital (in-cath lab) administration of the P2Y12 antagonist ticagrelor.
ATLANTIC was a 30-day, international, randomized, double-blind, placebo-controlled study in STEMI patients transferred for primary PCI. Immediately after diagnosis of STEMI, patients were randomized to receive either pre- or in-hospital ticagrelor 180 mg with matching placebo. All patients then received ticagrelor 90 mg bd for 30 days. The co-primary endpoints were percentage of patients not reaching ≥70% resolution of ST-segment elevation before PCI or not achieving TIMI flow grade 3 in the culprit artery at initial angiography. Clinical endpoints included rates of major adverse cardiovascular events (MACE) and definite stent thrombosis. The primary safety endpoint was major, life-threatening or minor bleeding (excluding coronary artery bypass graft [CABG]-related bleeding).
Between 12 Sept 2011 and 3 Oct 2013, 1862 patients from 13 countries were randomised to pre-hospital (n=909) or in-hospital ticagrelor (n=953).  Median time difference between the two groups for  ticagrelor loading dose was 31 min. There was no difference between the pre- and in-hospital groups in terms of absence of ≥70% ST segment resolution (86.8% vs 87.6%; OR 0.93 [95% CI 0.69, 1.25); p=0.63) or TIMI flow grade 3 (82.6 % vs 83.1%; OR 0.97 [95% CI 0.75, 1.25],; p=0.82), nor in overall rates of MACE at 30 days (4.5% vs 4.4%; p=0.91). A significant reduction in definite stent thrombosis was seen in the pre-hospital group both acutely (≤24 h) (0% vs 0.8%; p=0.0008) and at 30 days (0.2% vs 1.2%; OR 0.19 [95% CI 0.04,0.86]; p=0.0225) (Figure). There were no differences between the groups in rates of non-CABG-related major, life-threatening, or minor bleeding up to 48 h or 30 days, nor in overall or serious adverse event rates.
Pre-hospital ticagrelor administration a short time before PCI in patients with ongoing STEMI appears to be safe but does not improve pre-PCI coronary reperfusion. It may, however, reduce risk of post-PCI stent thrombosis.


By Paul Wayne Armstrong, FESC (Edmonton, Canada)
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This Randomised Clinical Trial on the role of early administration of ticagrelor in STEMI, conducted by Professor Montalescot and colleagues was aimed at evaluating two co-primary endpoints and indices of reperfusion i.e. ST elevation resolution and pre PCI TIMI coronary flow in 1892 patients with STEMI. Patients were randomized within 6 hours of symptom onset to either a loading dose of pre hospital ticagelor or one given at the time of primary PCI. Whereas the study failed to achieve its objectives it did provide evidence of excellent and timely therapy in a relatively low risk population with a remarkable low 30 day clinical event rate approximating 5% in death, MI, stroke and urgent revascularization.
Although the authors suggest that early stent thrombosis may have been mitigated by pre hospital ticagrelor the mal-alignment of this finding with other clinical events suggests the play of chance may have been more likely finding.
Of particular additional interest was the very short interval between the administration of the 2 therapies i.e. 31 minutes which was much briefer than that evident in prior studies of anti-platelet treatment strategies showing benefit in STEMI: this may have precluded the opportunity to demonstrate the expected therapeutic benefit. Hence the early pre-hospital role of ticagrelor remains to be established is still an open question.
The ATLANTIC investigators were potentially victimized by their own success in treating their patients so successfully in this trial.




Hot Line: Myocardial Infarction

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.