"Ticagrelor versus Prasugrel in Acute Coronary Syndromes".The New England Journal of Medicine. 2019.
Links to original sources: Wiki Journal Post Full Journal Article
In patients with acute coronary syndromes for whom invasive evaluation is planned, how does ticagrelor compare with prasugrel in preventing death, myocardial infarction, or stroke?
In patients with acute coronary syndromes with or without ST-segment elevation, prasugrel was associated with a significantly lower incidence of death, myocardial infarction, or stroke compared to ticagrelor at 1 year, without a significant difference in the incidence of major bleeding.
Prior trials have established the individual benefits of third-generation thienopyridine prasugrel and cyclopentyltriazolopyrimidine ticagrelor over clopidogrel in patients with acute coronary syndromes. However, direct comparisons of ticagrelor and prasugrel in this setting were lacking. The ISAR-REACT 5 trial aimed to address this gap by comparing the efficacy and safety of ticagrelor to prasugrel in patients with acute coronary syndromes for whom invasive evaluation was planned.
As of the time of the trial, both prasugrel and ticagrelor were recommended (class I) for use in patients with acute coronary syndromes with or without ST-segment elevation.
Multicenter, randomized, open-label, phase 4 trial comparing ticagrelor and prasugrel.
4,018 patients hospitalized with acute coronary syndromes (STEMI, NSTEMI, or unstable angina) with planned invasive evaluation.
Ticagrelor: Loading dose of 180 mg, maintenance dose of 90 mg twice daily. Prasugrel: Loading dose of 60 mg, maintenance dose of 10 mg daily; a reduced maintenance dose of 5 mg daily was recommended for patients aged 75+ or weight less than 60 kg. Prasugrel loading was administered after coronary anatomy was known in patients with acute coronary syndromes without ST-segment elevation.
Primary Outcome: Composite of death from any cause, myocardial infarction, or stroke at 1 year (ticagrelor 9.3% vs. prasugrel 6.9%; hazard ratio 1.36, 95% CI 1.09 to 1.70; P=0.006). Safety End Point: Major bleeding (BARC type 3 through 5) (ticagrelor 5.4% vs. prasugrel 4.8%; hazard ratio 1.12, 95% CI 0.83 to 1.51; P=0.46).
- Open-label design may introduce bias. - Most follow-up conducted by telephone, not face-to-face. - High incidence of switching to clopidogrel after discharge in a previous head-to-head comparison trial.
Funded by the German Center for Cardiovascular Research and Deutsches Herzzentrum München.
Details on the ISAR-REACT 5 trial can be found at NEJM.org and ClinicalTrials.gov number, NCT01944800.