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ATLANTIC Trial: Prehospital Ticagrelor for STEMI

Summary:

Ticagrelor (Brilinta) is a reversible, direct acting P2Y12 receptor antagonist which prevents ADP-mediated activation of GPIIb/IIIa receptor complexes thereby reducing platelet aggregation.  It is indicated for the management of patients with acute coronary syndrome.

  • The ATLANTIC trial was an international, multicentered, randomized, double-blind clinical trial of 1,862 patients with ongoing STEMI of < 6 hrs duration.
  • Giving ticagrelor pre-hospital vs. in the cath lab showed no advantage in resolution of ST-segment elevation, major adverse CV events or rates of bleeding, but did show a small benefit in definite stent thrombosis.

Take Home Point:
  • Compared to In-hospital administration, the prehospital administration of ticagrelor appears to be safe and may offer a small benefit in preventing stent thrombosis after more definitive treatment with PTCA and without any difference in major bleeding.

ATLANTIC Trial: Summary
  • Montalescot G, et al. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 2014;371(11):1016-27. PubMed
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    Study Design International, Multicenter, Randomized, Double-Blind study
    Sample Size n = 1,862 patients with ongoing STEMI of < 6 hrs
    Groups
    • n = 909 Pre-hospital administration of ticagrelor 180 mg x1, then 90 mg twice daily
    • n = 953 In-hospital administration of ticagerlor 180 mg x 1 in cath lab, then 90 mg twice daily
    Primary Endpoint

    The coprimary end points were:

    • The proportion of patients who did not have a 70% or greater resolution of ST-segment elevation before percutaneous coronary intervention (PCI)
    • The proportion of patients who did not have Thrombolysis in Myocardial Infarction flow grade 3 in the infarct-related artery at initial angiography
    Secondary Endpoint The rates of MACE and definite stent thrombosis at 30 days
    Follow Up 60 mins & 30 days
    Results
    • The two coprimary end points did not differ between the prehospital & in-hospital groups.
    • The absence of ST-segment elevation resolution of 70% or greater after PCI was 42.5% and 47.5%, respectively.
    • The rates of MACE did not differ significantly.
    • The rates of definite stent thrombosis were lower in the prehospital group than in the in-hospital group (0% vs. 0.8% in the first 24 hrs; 0.2% vs. 1.2% at 30 days).
    • No difference in major bleeding events.
    Conclusion Prehospital administration of ticagrelor in patients with acute STEMI appeared to be safe but did not improve pre-PCI coronary reperfusion.
    Funding AstraZeneca
    ClinicalTrials.gov NCT01347580
    Locations Austria, Denmark, France, Germany, Spain, United Kingdom, Australia, Hungry, Italy

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