Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes
Stefanie Schüpke1, Franz-Josef Neumann1, Maurizio Menichelli1
1From the Department of Cardiology, Deutsches Herzzentrum München, and Technische Universität München (S.S., K.M., M.J., R.H., S.C., E.X., S.K., G.N., H. Schunkert, A.K.), the German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance (S.S., D.S., H. Schunkert, K.-L.L., A.K.), the Department of Cardiology, Angiology, and Pulmonology, Medizinische Klinik und Poliklinik I, Klinikum rechts der Isar (I.B., R.O., K.-L.L.), the Department of Cardiology, Klinikum der Universität München, Ludwig-Maximilians-University (D.S.), and the Institute of Medical Informatics, Statistics, and Epidemiology, School of Medicine, Technische Universität München (A.H.), Munich, the Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen (F.-J.N., W.H., S.L., D.T.), the Department of Cardiology, Ulm University Hospital, Ulm (J.W., W.R.), the Heart Center Bad Segeberg, Bad Segeberg (G.R., A.A., R.T.), the Heart Center, Kerckhoff Campus of Justus-Liebig University, Giessen (C.L., H.M., C.W.H.), DZHK, Partner Site Rhine-Main, Bad Nauheim (C.W.H.), the Department of Cardiology and Pneumology, Helios Amper-Klinikum Dachau, Dachau (B.W., A.S.), the Department of Cardiology, University Clinic Mannheim (I.A.), and DZHK, Partner Site Heidelberg-Mannheim (I.A., H.A.K.), Mannheim, the Department of Cardiology, Klinikum Landkreis Erding, Erding (L.B.-F.), the Department of Internal Medicine II, University Medical Center Regensburg, Regensburg (M.F.), the Department of Cardiology, Charité-University Medicine Berlin (U.L.), Berlin Institute of Health (U.L.), DZHK, Partner Site Berlin (U.L.), and Vivantes Auguste-Viktoria-Klinikum (H. Schühlen), Berlin, the Department of Cardiology, University Clinic Heidelberg (H.A.K.), and DZHK, Partner Site Heidelberg-Mannheim (I.A., H.A.K.), Heidelberg, the Department of Cardiology, Helios University Hospital and University of Witten-Herdecke, Wuppertal (M.S.) - all in Germany; the Department of Cardiology, Ospedale Fabrizio Spaziani, Frosinone (M.M., D.B., P.M.), and Careggi University Hospital, Florence (D.A., A.M.) - both in Italy; and the Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.).
Insights
Prasugrel demonstrated superior efficacy over ticagrelor in preventing death, myocardial infarction, or stroke in acute coronary syndrome patients. Major bleeding rates were similar between the two antiplatelet therapies.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Uncertainty exists regarding the comparative effectiveness of ticagrelor versus prasugrel in acute coronary syndrome (ACS) patients undergoing invasive evaluation.
- Both ticagrelor and prasugrel are P2Y12 inhibitors used to prevent thrombotic events in ACS.
Purpose of the Study:
- To compare the efficacy and safety of ticagrelor versus prasugrel in patients with ACS planned for invasive evaluation.
- To determine which antiplatelet agent offers better outcomes in terms of major adverse cardiovascular events and bleeding.
Main Methods:
- A multicenter, randomized, open-label trial (ISAR-REACT 5) involving 4018 patients with ACS.
- Patients were assigned to receive either ticagrelor or prasugrel.
- The primary endpoint was a composite of death, myocardial infarction, or stroke at 1 year; a key safety endpoint was major bleeding.
Main Results:
- The primary endpoint occurred in 9.3% of the ticagrelor group versus 6.9% of the prasugrel group (HR, 1.36; P=0.006), indicating a higher event rate with ticagrelor.
- Individual components showed higher rates of myocardial infarction (4.8% vs 3.0%) and death (4.5% vs 3.7%) in the ticagrelor arm.
- Major bleeding rates were similar between groups (5.4% for ticagrelor vs 4.8% for prasugrel; P=0.46).
Conclusions:
- Prasugrel was associated with a significantly lower incidence of death, myocardial infarction, or stroke compared to ticagrelor in ACS patients.
- The safety profile, specifically major bleeding, was comparable between prasugrel and ticagrelor.
- These findings suggest prasugrel may be a preferred treatment option for ACS patients undergoing invasive procedures.
Background:
The relative merits of ticagrelor as compared with prasugrel in patients with acute coronary syndromes for whom invasive evaluation is planned are uncertain.
Methods:
In this multicenter, randomized, open-label trial, we randomly assigned patients who presented with acute coronary syndromes and for whom invasive evaluation was planned to receive either ticagrelor or prasugrel. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. A major secondary end point (the safety end point) was bleeding.
Results:
A total of 4018 patients underwent randomization. A primary end-point event occurred in 184 of 2012 patients (9.3%) in the ticagrelor group and in 137 of 2006 patients (6.9%) in the prasugrel group (hazard ratio, 1.36; 95% confidence interval [CI], 1.09 to 1.70; P = 0.006). The respective incidences of the individual components of the primary end point in the ticagrelor group and the prasugrel group were as follows: death, 4.5% and 3.7%; myocardial infarction, 4.8% and 3.0%; and stroke, 1.1% and 1.0%. Definite or probable stent thrombosis occurred in 1.3% of patients assigned to ticagrelor and 1.0% of patients assigned to prasugrel, and definite stent thrombosis occurred in 1.1% and 0.6%, respectively. Major bleeding (as defined by the Bleeding Academic Research Consortium scale) was observed in 5.4% of patients in the ticagrelor group and in 4.8% of patients in the prasugrel group (hazard ratio, 1.12; 95% CI, 0.83 to 1.51; P = 0.46).
Conclusions:
Among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups. (Funded by the German Center for Cardiovascular Research and Deutsches Herzzentrum München; ISAR-REACT 5 ClinicalTrials.gov number, NCT01944800.).
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