p.23 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e793

Recommendation-Specific Supporting Text

1 CHAMPION PHOENIX (A Clinical Trial Comparing

Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require PCI) examined the effect of cangrelor versus clopidogrel in patients undergoing PCI for acute or stable coronary syndromes.2 Cangrelor was administered as an intravenous bolus prior to PCI followed by an infusion for at least 2 hours or for the duration of the procedure, whichever was longer. In the control arm, clopidogrel was administered as a 600- or 300-mg loading dose immediately before or after PCI. At 48 hours, the primary endpoint of allcause death, MI, ischemia-driven revascularization, or stent thrombosis was significantly reduced with cangrelor with similar effects observed among those presenting with NSTE-ACS (n=2810) or STEMI (n=1991). These results contrast with the earlier neutral findings from the CHAMPION PLATFORM (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) trial and CHAMPION PCI (A Clinical Trial to Demonstrate the Efficacy of Cangrelor), which compared cangrelor with placebo and clopidogrel, respectively.1,3 Differences across trials in the timing of clopidogrel administration and definitions of MI and stent thrombosis may in part account for variability in the incidence of ischemic events and observed treatment effect. In a pooled analysis of these trials, cangrelor was associated with a significant reduction in periprocedural ischemic events compared with control with no evidence of heterogeneity across types of ACS presentations.4

4.3.4 Intravenous Glycoprotein IIb/IIIa Inhibitors

Recommendations for Intravenous Glycoprotein IIb/IIIa Inhibitors Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

2a C-LD 1 In patients with ACS undergoing PCI with large

thrombus burden, no-reflow, or slow flow, adjunctive use of an intravenous or intracoronary glycoprotein IIb/IIIa inhibitor is reasonable to improve procedural success and reduce infarct size.*,1,2 3: Harm B-R 2 In patients with ACS, glycoprotein IIb/IIIa

inhibitors should not be administered routinely due to lack of ischemic benefit and increased risk of bleeding.3–5

*Adapted from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”6

Synopsis Glycoprotein IIb/IIIa receptor inhibitors are parenterally administered drugs that block platelet aggregation by preventing platelet cross-linking via fibrinogen or von Willebrand factor binding to the glycoprotein IIb/IIIa receptor. These agents were first evaluated before contemporary antiplatelet and interventional strategies were introduced and in an era when the time to coronary revascularization was substantially longer than today. Thus, limited data are available for glycoprotein IIb/IIIa receptors in patients receiving more potent P2Y12 inhibitors and in those receiving earlier PCI with contemporary drug-eluting stents that have a lower risk for stent thrombosis than prior generations of stents. In current practice, the role of glycoprotein IIb/IIIa receptor inhibitors is largely limited to adjunctive use at the time of PCI in patients with large thrombus burden or as “rescue” or “bailout” therapy in patients with PCI complications such as no-reflow or persistent or recurring thrombus at the lesion.1

Recommendation-Specific Supportive Text

1 In a study of 452 selected high-risk patients with

large anterior STEMI and a large thrombus burden, adjunctive use of intracoronary abciximab reduced thrombus burden and infarct size.1 Other trials have also suggested that glycoprotein IIb/IIIa inhibitors can reduce intracoronary thrombus burden in patients with STEMI and NSTE-ACS.7,8 Thus, glycoprotein IIb/IIIa receptor inhibitors can be considered at the time of PCI for patients with a large coronary thrombus burden or no-reflow or slow flow that is believed to be attributable to distal embolization of thrombus. In clinical trials comparing intravenous and intracoronary administration of glycoprotein IIb/IIIa inhibitors, clinical and bleeding outcomes, as well as thrombus resolution and infarct size, have generally been similar.2,9,10

2 Multiple strategies have been evaluated for use of

glycoprotein IIb/IIIa receptor inhibitors in patients with ACS. “Upstream” administration of these agents is defined as administration of small molecule agents (eptifibatide or tirofiban) early after

Table 9.  Transition From Intravenous Cangrelor Infusion to Oral P2Y12 Inhibitor

Oral P2Y12 inhibitor Loading Dose Timing of Loading Dose Administration Clopidogrel 600 mg Immediately after discontinuation of cangrelor Prasugrel 60 mg Immediately after discontinuation of cangrelor Ticagrelor 180 mg At any time during or immediately after discontinuation of cangrelor Recommendations in table obtained from US Food and Drug Administration labeling for cangrelor.8 Recommendations for Intravenous Glycoprotein IIb/IIIa Inhibitors (Continued )

COR LOE Recommendations

Downloaded from http://ahajournals.org by on October 7, 2026