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In patients presenting with an ST-segment elevation myocardial infarction (STEMI), the 2013 STEMI guidelines currently recommend percutaneous coronary intervention (PCI) as the primary method for reperfusion.1 Appropriate antiplatelet therapies include a loading dose of aspirin (162-325mg) in addition to a loading dose of a P2Y12 inhibitor given as early as possible or at time of PCI (clopidogrel 600mg, prasugrel 60mg, or ticagrelor 180mg).1 Among the P2Y12 inhibitors, the PLATO trial demonstrated that ticagrelor started in-hospital reduced cardiovascular outcomes and all-cause mortality compared to clopidogrel.2 The full antiplatelet effect of ticagrelor, however, is not likely seen for up to an hour, thus warranting the hypothesis that earlier administration may improve outcomes.2  This concept was first investigated in STEMI patients who received pre-hospital administration with the glycoprotein IIb/IIIa inhibitor abiximab, which was associated with a higher rate of Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 before primary PCI and lower rates of ischemic events, when compared to placebo.3  Therefore, the ATLANTIC trial mimicked this concept, and investigated whether earlier administration of ticagrelor (pre-hospital/ ambulance administration) compared to in-hospital administration would result in better clinical outcomes.4

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The ATLANTIC trial was an international, multicenter, randomized, double-blind, double-dummy study which compared pre-hospital (in the ambulance) admission of ticagrelor versus in-hospital administration in patients with an ongoing STEMI.4 The co-primary endpoints were the proportion of patients who did not have a ≥70% resolution in ST-segment elevation before PCI, and the proportion of patients who did not have Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in the infarct-related artery at first angiography. Secondary end points included the rates of major adverse cardiovascular events (MACE) and definite stent thrombosis at 30 days.  The safety endpoints were major bleeding, life-threatening bleeding, and minor bleeding after the first 48 hours and at 30 days measured using multiple bleeding scales. Patients received a 180mg loading dose of ticagrelor in the ambulance and placebo in the catheterization lab (in-hospital), or a placebo in the ambulance and 180mg in the catheterization lab. Patients then received ticagrelor 90mg BID for 30 days and a recommendation to extend its use to a year. Patients were included in the study if, they provided written, informed consent, were ≥18 years old, had symptoms of acute MI of more than 30 minutes but less than 6 hours, and had a new ST-segment elevation of ≥1mm in 2 or more ECG leads. Exclusion criteria included pregnancy, expected time to catheterization lab >120 minutes, active bleeding, patients at high risk for bleeding, patients requiring concomitant chronic anticoagulation therapy, and patients having a contraindication to ticagrelor.4

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A total of 1862 patients were randomized to one of the two treatment groups with a median time to angiography of 48 minutes.4 The baseline characteristics were similar between both groups, except for a small, non-significant difference in patients with TIMI scores of >6 (patients ...

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