(233) Evaluation of Tirofiban Versus Cangrelor for Bridge Therapy During Mechanical Circulatory Support

Introduction: Cangrelor was recently added to formulary as an alternative bridging agent to tirofiban for high bleed risk patients supported on mechanical circulatory support (MCS). This study was designed to assess the safety/efficacy of tirofiban versus (vs) cangrelor for periprocedural bridging during MCS.

Methods: Single-center, retrospective, pre/post, cohort study of adult cardiac intensive care unit (ICU) patients requiring intravenous (IV) antiplatelet therapy for periprocedural bridging while supported on MCS. Patients were included if they received tirofiban from April 2022-April 2023 (tirofiban group) or cangrelor from May 2023-May 2024 (cangrelor group). The primary endpoint was the difference in major bleeding (Bleeding Academic Research Consortium (BARC) type 3 or greater) between groups. Secondary endpoints included differences in minor bleeding (BARC type 1 or 2), transfusion requirements, major cardiac events (stent thrombosis or stroke), length of stay, mortality, and direct medication cost. Data was analyzed using Fisher exact test for categorical data and Wilcoxon rank sum for continuous data.

Results: A total of 51 patients were included (30 tirofiban and 21 cangrelor; (median (IQR) age 61 (54-65) years, 71% male). Majority of patients (82%) had coronary stents less than 30 days old. Most common MCS was Impella (41%) or VA-ECMO + Impella (25%). There was a trend towards reduced major bleeding (73% tirofiban vs 48% cangrelor; p=0.082) with cangrelor and no difference in minor bleeding (3% tirofiban vs 5% cangrelor; p=1.0). Cangrelor patients required significantly less packed red blood cells vs tirofiban (3.7 vs 7.3 units; p=0.038). There were two instances of ischemic stroke in the tirofiban group and one with cangrelor. There were no instances of stent thrombosis. ICU length of stay (21 vs 18 days) and mortality (47% vs 33%) were similar between tirofiban and cangrelor groups, respectively. Average daily cost of tirofiban was $158/patient/day vs $1,970/patient/day for cangrelor.

Conclusions: Cangrelor was associated with a trend towards reduced major bleeding and significantly reduced transfusion requirements compared to tirofiban. Larger studies are needed to confirm these findings and assess IV antiplatelet therapy cost-effectiveness.