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For treatment of acute coronary syndrome, prasugrel is better than ticagrelor at preventing recurrent MIs at 1 year
Clinical Question
For patients who present with acute coronary syndrome and for whom invasive evaluation is planned, which antiplatelet therapy, ticagrelor or prasugrel, produces better outcomes?
Bottom line
In patients with acute coronary syndrome (ACS), prasugrel performed better than ticagrelor to prevent recurrent myocardial infarction (MI) and did not lead to an increased rate of major bleeding. Treating 56 people with ticagrelor instead of prasugrel would result in one additional MI at 1 year. 1b
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
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).
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL