Ticagrelor or Prasugrel in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes
Christian Valina1, Franz-Josef Neumann1, Maurizio Menichelli2
1Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
Insights
Prasugrel demonstrated superiority over ticagrelor in reducing the risk of death, myocardial infarction, or stroke in patients with non-ST-segment elevation acute coronary syndromes. This benefit was observed without an increase in bleeding events.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Current guidelines recommend intensified platelet inhibition with prasugrel or ticagrelor for unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI).
- Non-ST-segment elevation acute coronary syndromes (NSTE-ACS) require effective antiplatelet strategies.
Purpose of the Study:
- To compare the efficacy and safety of ticagrelor versus prasugrel in patients with NSTE-ACS undergoing planned invasive management.
- To evaluate the combined endpoint of death, myocardial infarction (MI), or stroke, and the incidence of major bleeding.
Main Methods:
- A post hoc analysis of the ISAR-REACT 5 trial, combining pre-specified subgroups of UA and NSTEMI.
- 1,179 patients received ticagrelor (initiated immediately post-randomization) and 1,186 received prasugrel (initiated after coronary angiography).
- Primary endpoint: composite of death, MI, or stroke at 1-year. Safety endpoint: Bleeding Academic Research Consortium (BARC) class 3-5 bleeding.
Main Results:
- The primary endpoint occurred in 8.7% of the ticagrelor group versus 6.3% of the prasugrel group (HR: 1.41; 95% CI: 1.04-1.90).
- No significant difference in all-cause death or MI between groups.
- BARC class 3-5 bleeding occurred in 5.2% of the ticagrelor group versus 4.7% of the prasugrel group (HR: 1.09; 95% CI: 0.72-1.65).
Conclusions:
- Prasugrel was superior to ticagrelor in reducing the combined 1-year risk of death, MI, and stroke in NSTE-ACS patients without increasing bleeding risk.
- These findings, from a post hoc analysis, warrant confirmation in further prospective studies.
Background:
Current guidelines recommend intensified platelet inhibition by prasugrel or ticagrelor in patients with unstable angina (UA) or non-ST-segment elevation (NSTE) myocardial infarction (MI).
Objectives:
This study sought to investigate the benefits and risks of ticagrelor as compared with prasugrel in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and planned invasive management.
Methods:
This post hoc analysis combines the pre-specified subgroups of UA and NSTEMI of the randomized ISAR-REACT 5 trial. It included 1,179 patients assigned to ticagrelor and 1,186 assigned to prasugrel. Ticagrelor was started immediately after randomization and prasugrel after coronary angiography. The primary endpoint was a composite of death, MI, or stroke during 1-year follow-up, and the safety endpoint was Bleeding Academic Research Consortium class 3-5.
Results:
The primary endpoint was reached in 101 (8.7%) patients in the ticagrelor and in 73 (6.3%) patients in the prasugrel group (hazard ratio [HR]: 1.41; 95% confidence interval [CI]: 1.04 to 1.90). The HR for all-cause death was 1.43 (95% CI: 0.93 to 2.21) and that for MI 1.43 (95% CI: 0.94 to 2.19). The safety endpoint occurred in 49 (5.2%) patients in the ticagrelor and in 41 (4.7%) patients in the prasugrel group (HR: 1.09; 95% CI: 0.72 to 1.65). Landmark analysis revealed persistence of the efficacy advantage with prasugrel after the first month.
Conclusions:
In patients with NSTE-ACS, we found that prasugrel was superior to ticagrelor in reducing the combined 1-year risk of death, MI, and stroke without increasing the risk of bleeding. Due to the post hoc nature of the analysis, these findings need confirmation by further studies. (Prospective, Randomized Trial of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome; NCT01944800).
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