Lit Matters 1: ATLANTIC

Prehospital ticagrelor in STEMI did not improve pre-PCI reperfusion in ATLANTIC, despite a biologically plausible push to start P2Y12 inhibition earlier. The trial helped simplify prehospital and ED STEMI care while leaving a signal of possible early stent-thrombosis benefit.

Prehospital Ticagrelor in STEMI

• Trial question and drug: ATLANTIC tested whether a 180 mg ticagrelor load given before hospital arrival could improve coronary reperfusion before PCI in ECG-confirmed STEMI.
• Hard primary endpoints: The co-primary endpoints were tough markers of early reperfusion: at least 70% ST-segment resolution before PCI and TIMI 3 flow on initial angiography.
• Negative main result: Earlier ticagrelor did not improve either pre-PCI reperfusion endpoint, so the central prehospital strategy failed despite strong physiologic rationale.
• Safety and thrombosis signal: Major adverse cardiac events were unchanged, but definite stent thrombosis was lower with prehospital dosing at 24 hours and again at 30 days, a nuance we get into in the episode.
• Timing as key limitation: The gap between field dosing and PCI was relatively short, which likely blunted any chance for ticagrelor to show a measurable pre-PCI effect.
• Practice-level implication: A negative, logistically difficult STEMI trial still mattered because it supported incremental simplification of prehospital and ED antiplatelet workflows.