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BMJ 2009; 339 doi: (Published 25 November 2009) Cite this as: BMJ 2009;339:b4963

New intravenous antiplatelet agent disappoints in early trials

The first antiplatelet agent that is potent, fast acting, reversible, and readily controlled by intravenous infusion (cangrelor) has been tested in patients having a percutaneous coronary intervention (PCI). Results from twin trials were disappointing. Compared with clopidogrel, the new drug did not reduce the risk of death, heart attack, or revascularisation in the two days after PCI. The combined primary end point occurred in 7-8% of patients. Cangrelor was associated with a significantly higher risk of minor bleeding in both trials and a higher risk of major bleeding, which approached statistical significance in one trial (odds ratio 1.26, 95% CI 0.99 to 1.60).

Together, the trials included more than 14 000 patients scheduled for PCI, mostly for acute coronary syndrome. Cangrelor was started after angiography but before PCI in both trials and given for the duration of the procedure. Controls had clopidogrel alone, which was started before PCI in one trial and after in the other. Both trials ended early, when data monitoring committees decided that further recruitment wouldn’t alter the primary results. An editorial (doi:10.1056/nejme0910677) argues that this decision seriously undermined secondary results, some of which favoured cangrelor.

Further trials are still justified, it says. These trials were brief and complicated by treatment strategies that don’t match current guidelines, a confusion of different primary analyses, and at least three different definitions of bleeding complications.

“Innocuous” ECG abnormality linked to cardiac deaths

The J point joins the QRS complex to the beginning of the ST segment on a 12 lead electrocardiogram (ECG). A raised or spiked J point was thought to be an innocuous sign of early repolarisation, but a cohort study from Finland recently found that middle aged adults with this abnormality had an increased risk of death from heart disease.

The link was strongest for men and women with a raised J point …

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