Prehospital Ticagrelor in Patients with ST-Segment Elevation Myocardial Infarction with Long Transport Time to Primary PCI Facility

Background: Pre-hospital ticagrelor, given less than 1 hour before coronary intervention (PCI), failed to improve coronary reperfusion in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI. It is unknown whether a longer interval from ticagrelor administration to primary PCI might reveal any improvement of coronary reperfusion.
Methods: we retrospectively compared 143 patients, pre-treated in spoke centres or ambulance with ticagrelor at least 1.5 hours before PCI (Pre-treatment Group), with 143 propensity score-matched controls treated with ticagrelor in the hub before primary PCI (Control Group) extracted from RENOVAMI, a large observational Italian registry of more than 1400 STEMI patients enrolled from Jan 2012 to Oct 2015 (ClinicalTrials.gov id: NCT01347580). The median time from ticagrelor administration and PCI was 2.08 hours (95% CI 1.66-2.84) in the Pre-treatment Group and 0.56 hours (95% CI 0.33-0.76) in the Control Group. TIMI flow grade before primary PCI in the infarct related artery was the primary end point.
Results: The primary end point, baseline TIMI flow grade, was significantly higher in Pre-treatment Group (0.88 ± 1.14 vs 0.53 ± 0.86, P = 0.02). However in hospital mortality, in hospital stent thrombosis, bleeding rates and other clinical and angiographic outcomes were similar in the two groups.
Conclusions: In a real world STEMI network, pre-treatment with ticagrelor in spoke hospitals or in ambulance loading at least 1.5 hours before primary PCI is safe and might improve pre-PCI coronary reperfusion, in comparison with ticagrelor administration immediately before PCI.