"Ticagrelor versus Prasugrel in Acute Coronary Syndromes".The New England Journal of Medicine. 2019.

Clinical Question

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?

Bottom Line

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.

Major Points

Guidelines

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.

Design

Multicenter, randomized, open-label, phase 4 trial comparing ticagrelor and prasugrel.

Population

4,018 patients hospitalized with acute coronary syndromes (STEMI, NSTEMI, or unstable angina) with planned invasive evaluation.

Interventions

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.

Outcomes

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).

Criticisms

- 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.

Funding

Funded by the German Center for Cardiovascular Research and Deutsches Herzzentrum München.

Further Reading