George Dangas; Johny Nicolas; Paul Harbich; Kurt Huber

doi:10.4244/EIJ-E-23-00070

Guideline recommendations for cangrelor should be upgraded: pros and cons

George Dangas¹, MD, PhD; Johny Nicolas¹, MD, MSc; Paul Harbich², MD; Kurt Huber²^,³, MD

Introduction

Cangrelor is an intravenous (IV) P2Y12 receptor inhibitor that is characterised by high potency and a more rapid onset and offset of the pharmacological effect as compared to oral P2Y12 inhibitors. The latest European guidelines on acute coronary syndromes (ACS) recommend its use in P2Y12 receptor inhibitor-naïve patients undergoing percutaneous coronary intervention (PCI). This statement has been provided with a Class IIb recommendation and a Level of Evidence A, therefore meaning that the current evidence on the use of cangrelor is still not definitive. Randomised trials of cangrelor have yielded mixed results, and a meta-analysis of these trials has shown that cangrelor was associated with reduced ischaemic events and increased minor bleeding. However, the benefit of cangrelor was reduced when compared to upfront clopidogrel, and no conclusive data are available in case of administration of potent oral P2Y12 inhibitors (i.e., prasugrel or ticagrelor). Based on current evidence, cangrelor is not the standard antithrombotic strategy for unselected ACS patients undergoing PCI, and whether the current recommendation should be upgraded is a matter of debate.