For treatment of acute coronary syndrome, prasugrel is better than ticagrelor at preventing recurrent MIs at 1 year

Référence

Schupke S, Neumann FJ, Menichelli M, et al, for the ISAR-REACT 5 Trial Investigators. Ticagrelor or prasugrel in patients with acute coronary syndromes. N Engl J Med 2019;381(16):1524-34. Nikooie R, Neufled KJ, Oh ES et al. Antipsychotics for treating delirium in hospitalized adults. Ann Inter Med. 3 September 2019 [Epub ahead of print] doi.10.7326/M19-1860

Sommaire

In this multicenter trial, patients hospitalized for ACS (ST-segment elevation myocardial infarction [STEMI], non-ST segment elevation myocardial infarction [NSTEMI], or unstable angina) with a plan for coronary angiography were randomized to receive either ticagrelor or prasugrel. The 2 groups were similar at baseline: 46% had NSTEMI, 41% had STEMI, and 13% had unstable angina. In the ticagrelor group (n = 2012), patients received a loading dose of 180 mg as pretreatment to coronary angiography and a maintenance dose of 90 mg twice daily. In the prasugrel group (n = 2006), patients received a loading dose of 60 mg (deferred until after coronary angiography for patients without ST-elevation) and a maintenance dose of 10 mg daily. Of the entire study population, 84% underwent percutaneous coronary intervention, 2% underwent coronary artery bypass grafting, and 14% had conservative treatment with medications only. At the 1-year follow-up, 15% of the ticagrelor group and 13% of the prasugrel group had discontinued the study medication. For the primary end point of the composite of all-cause death, myocardial infarction, or stroke at 1 year, the ticagrelor group fared worse than the prasugrel group (event rate at 1 year of 9.3% vs 6.9%; hazard ratio [HR] 1.36; 95% CI 1.09 - 1.70; P = .006). This was driven primarily by the incidence of myocardial infarction (4.8% in ticagrelor group vs 3.0% in the prasugrel group; HR 1.63; 1.18 - 2.25). In a modified intention-to-treat analysis of all patients who received at least one dose of the study drug, no significant differences were detected in the rate of major bleeding (5.4% in ticagrelor group vs 4.8% in prasugrel group; HR 1.12; 0.83 - 1.51; P = 0.46).