In the 2025 ACC/AHA/ACEP/NAEMSP/SCAI acute coronary syndrome (ACS) guideline, cangrelor is listed as an option for ACS patients undergoing percutaneous coronary intervention (PCI) who have not been pretreated with an oral P2Y12 inhibitor (Class IIb, Level B-R). In the 2023 ESC ACS guideline, cangrelor is placed as an intravenous P2Y12 inhibitor that may be considered in P2Y12-inhibitor–naïve patients undergoing PCI in ST-elevation myocardial infarction (STEMI) and non-ST elevation ACS (Class IIb). The 2021 ESC/EAPCI/ACCA consensus document similarly states that parenteral therapy should be used to cover the delayed onset of oral P2Y12 inhibitors and that cangrelor is preferred unless no-reflow or bailout occurs, in which case glycoprotein IIb/IIIa inhibitors may be used. Collectively, these documents place cangrelor as an intravenous (IV) P2Y12 inhibitor for P2Y12-naïve patients undergoing PCI, while glycoprotein IIb/IIIa inhibitors remain the agents explicitly designated for bailout therapy. [1], [2], [3]
A 2023 retrospective analysis evaluated the use of cangrelor in high-risk patients undergoing PCI for acute myocardial infarction (AMI) complicated by cardiac arrest (CA) and/or cardiogenic shock (CS). The study examined the challenge of delayed oral P2Y12 inhibitor onset in CA or CS, particularly in the presence of therapeutic hypothermia or morphine-and assessed whether intravenous cangrelor could provide rapid and reversible platelet inhibition in this setting. The cohort included 303 patients from Austria and Germany, all presenting with AMI and either heart failure requiring ventilation, CA, CS, or both. Cangrelor was initiated before PCI in 12.9% of cases and infused for a mean of 121 minutes. Within the first 48 hours after PCI, stent thrombosis or myocardial re-infarction occurred in only two patients (0.7%). The Bleeding Academic Research Consortium (BARC) 2–3 bleeding was reported in 11.2% of patients, with BARC 5 fatal bleeding in 3.3%. Total in-hospital mortality was 41.6%. In a matched comparison with patients from the CULPRIT-SHOCK trial, cangrelor use was associated with comparable thrombolysis in myocardial infarction (TIMI) 3 flow and numerically fewer ischemic events. These findings support cangrelor’s ability to reduce early ischemic complications in CA and CS patients and suggest an acceptable safety profile in this population. However, this study did not evaluate cangrelor initiated specifically as a bailout treatment for intraprocedural thrombotic complications. [4]
In a 2025 retrospective analysis of 493 high-risk PCI patients receiving cangrelor, most of whom presented with ACS (78.7%, including 29.6% STEMI and 14.8% cardiogenic shock) and underwent complex PCI (79.3%), investigators primarily evaluated real-world use patterns and transition strategies. Cangrelor was commonly used for thrombus-containing lesions or intraprocedural thrombotic complications (51.5%). Transition to ticagrelor occurred in 80.5% of patients and was associated with lower in-hospital MACCE compared with transition to thienopyridines (9.8% vs. 24.0%), and protocol-adherent transitions similarly reduced major adverse cardiac and cerebrovascular events (MACCE) (10.9% vs. 19.4%). Extended low-dose infusions were well tolerated in critically ill patients. However, although thrombotic complications were frequent indications, this study did not evaluate cangrelor initiated specifically as a bailout intervention after events such as slow-flow, no-reflow, or acute stent thrombosis. [5]