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Cangrelor reduced ischemic PCI complications more than clopidogrel without increasing severe bleeding

Ann Intern Med. 2013;158(12):JC5. doi:10.7326/0003-4819-158-12-201306180-02005
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CHAMPION-PHOENIX: Not so champion.
Posted on June 27, 2013
Anil Pandit, MD
Division of Cardiovascular Diseases, Mayo Clinic, Arizona
Conflict of Interest: None Declared

Dear Editor:I read, “Cangrelor reduced ischemic PCI complications more than clopidogrel with increasing severe bleeding,” with a great interest. The authors have done a remarkable job summarizing the findings of the study. However, the commentary misses several important points regarding CHAMPION-PHOENIX trial:

1. There was no difference in Q wave MI between study groups (OR 0.61, 95% CI = 0.29-1.29, P = 0.19), which carries clinical significance rather than biomarkers positive myocardial infarction.

2. Loading dose of clopidogrel was either 300 or 600 mg at the discrention of treating physician. Obiviously, 300 mg is inferior to 600 mg loading dose of clopidogrel leading to suboptimal efficacy in those receiving 300 mg. About one third of patients in the trial were treated with 300 mg loading dose of clopidogrel.

3. Although risk of stent thrombosis and myocardial infarction was lower in cangrelor group, these findings did not translate into lower risk of ischemia driven revascularization (OR 0.74, 95% CI = 0.45-1.20) and death (OR 1.0, 95% CI = 0.52-1.92).

4. Median time from admission to PCI in the trial was 4.4 hours. But, by the definition of biomarkers positive MI requires two samples drawn at least 6 hours apart. It is unlikely that patients in the trial had two sets of biomarkers before PCI.5. Stratifying data based on biomarkers positive and negative would have yielded better information from the trial, which was not performed.In summary, although cangrelor use was associated with reduction in primary end point compared with clopidogrel. The benefit was mainly driven by reduced risk of stent thrombosis and myocardial infarction. The reduction in myocardial infarction and stent thrombosis did not translate into reduction of ischemia driven revascularization and death. Based on these points, the role of cangrelor in PCI is questionable.

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