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Comparative Effectiveness of Prasugrel Versus Ticagrelor in Dialysis-Dependent End Stage Renal Disease Patients
Usman Ali Akbar1, Waleed Alruwaili2, Jordan L Lacoste3
1Department of Medicine, WVU Medicine - Camden Clark Medical Center, Parkersburg, West Virginia.
Insights
For patients with end-stage renal disease (ESRD) on dialysis undergoing percutaneous coronary intervention (PCI), prasugrel demonstrated a lower risk of death compared to ticagrelor. This study highlights prasugrel as a potentially safer P2Y₁₂ inhibitor in this high-risk population.
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- End-stage renal disease (ESRD) patients undergoing percutaneous coronary intervention (PCI) are a high-risk group with undefined optimal P2Y₁₂ inhibition.
- Major antiplatelet trials excluded ESRD patients, limiting evidence for prasugrel and ticagrelor use in this population.
Purpose of the Study:
- To compare the effectiveness and safety of prasugrel versus ticagrelor in dialysis-dependent ESRD patients after PCI.
- To evaluate major adverse cardiovascular events (MACE), including all-cause mortality, myocardial infarction (MI), and stroke.
Main Methods:
- A real-world cohort study using a US electronic health record network.
- Identified 920 propensity-score matched pairs of ESRD patients on dialysis receiving prasugrel or ticagrelor post-PCI (2011-2024).
- Assessed MACE and major bleeding over a median 11.2-month follow-up.
Main Results:
- Prasugrel was associated with a significantly lower risk of all-cause mortality compared to ticagrelor (HR 0.72, p=0.025).
- No significant differences were observed in MI, stroke, or major bleeding rates between the two groups.
- A trend towards lower major bleeding with prasugrel was noted (p=0.06).
Conclusions:
- In dialysis-dependent ESRD patients undergoing PCI, prasugrel use was linked to reduced all-cause mortality versus ticagrelor.
- Prasugrel did not increase the risk of major bleeding in this high-risk cohort.
- These findings suggest prasugrel may be a preferred P2Y₁₂ inhibitor for ESRD patients on dialysis post-PCI.
Abstract:
End-stage renal disease (ESRD) patients undergoing percutaneous coronary intervention (PCI) represent a high-risk, understudied population in whom optimal P2Y₁₂ inhibition remains undefined. Landmark trials demonstrated the superiority of prasugrel and ticagrelor over clopidogrel; however, ESRD patients were largely excluded. We aimed to compare the effectiveness and safety of prasugrel versus ticagrelor in a real-world cohort of dialysis-dependent ESRD patients undergoing PCI. Using a large US-based electronic health record network, we identified 920 propensity-score matched pairs of ESRD patients on dialysis who received either prasugrel or ticagrelor following PCI between 2011 and 2024. The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), or stroke, defined as major adverse cardiovascular events (MACE). Over a median follow-up duration of 11.2 months, prasugrel was associated with a significantly lower risk of all-cause mortality (Hazard Ratio [HR] 0.72, 95% confidence interval [CI] 0.56 to 0.92, p = 0.025) compared to ticagrelor. There were no significant differences in the rates of MI, stroke, or major bleeding between the 2 groups, although there was a trend toward lower major bleeding with prasugrel (p = 0.06). In conclusion, in this large, real-world study of ESRD patients on dialysis undergoing PCI, prasugrel was associated with a lower risk of all-cause mortality compared to ticagrelor, without an increased risk of major bleeding.
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