Effect of intravenous fentanyl on ticagrelor absorption and platelet inhibition among patients undergoing percutaneous coronary intervention: The PACIFY randomized clinical trial (platelet aggregation with ticagrelor inhibition and fentanyl)

Fentanyl is a potent opiate commonly administered during cardiac catheterization procedures in North America.1 The question of whether fentanyl could have adverse consequences in patients undergoing percutaneous coronary intervention (PCI) is raised by recent research demonstrating that intravenous morphine significantly delays the absorption of oral P2Y12 platelet inhibitors.2 The presumed mechanism is slowed gastric emptying. The single-center PACIFY trial (Platelet Aggregation With Ticagrelor Inhibition and Fentanyl; ClinicalTrials.gov. Unique identifier: NCT02683707) randomized adults undergoing clinically indicated elective coronary angiography to receive the procedure with or without intravenous fentanyl.3 The study was approved by the Johns Hopkins Medicine Institutional Review Board, and all participants provided written informed consent. Eligible adults had not received P2Y12 inhibitors for 14 days before enrollment. Other exclusion criteria included preprocedural treatment with oral anticoagulants or opiates, platelet count <100 000/mm3, and impaired renal or hepatic function. All participants received subcutaneous lidocaine and intravenous midazolam at the start of the catheterization procedure and as needed thereafter. Doses of all drugs were at the discretion of treating providers. Patients and outcomes assessors were blinded; treating providers were not. Participants who required PCI received an oral dose of 180 mg ticagrelor at the conclusion of diagnostic angiography. Blood samples were collected at baseline and 0.5, 1, 2, 4, and 24 hours after the …