Cangrelor (Kengreal) is an intravenous P2Y12 platelet inhibitor which is run as a continuous infusion. Unlike clopidogrel (Plavix) which is a prodrug requiring conversion to an active metabolite, cangrelor is already active and has a quick onset. Furthermore, stopping the infusion results in rapid restoration of platelet function in ~1 hour.

As a cardiovascular intensivist, this medication is incredibly useful in patients with recent acute coronary syndrome with subsequent stent placement who remain in the perioperative phase potentially requiring larger surgeries. If they need to go to the operating room, turning off the cangrelor infusion will improve primary hemostasis intraoperatively but risk thrombosis of the stent(s). Bleeding versus clotting is a balance we are constantly evaluating in the CVICU and cardiovascular operating rooms, so decisions are often a consensus between surgeons, anesthesiologists, and intensivists.

Dyspnea, which seems to be more associated with reversible P2Y12 inhibitors, is a symptom I watch for. Proposed mechanisms include reversible binding/unbinding of platelets with pulmonary sequestration, dysregulation of neuronal signaling (inhibition of P2 receptors on neuronal tissue), increased plasma adenosine due to increased RBC release of ATP, etc.

Drop me a comment with your experience regarding cangrelor!

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