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Prof. Gilles Montalescot,
Prof. Paul Wayne Armstrong,
By Gilles Montalescot, FESC (Paris, France)View Discussant report
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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
BackgroundThe 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.MethodsATLANTIC 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).ResultsBetween 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.ConclusionsPre-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)See Presenter abstract
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Hot Line: Myocardial Infarction
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