Prasugrel Bests Ticagrelor in Acute Coronary Syndrome Care

TOPLINE:

Prasugrel is associated with lower rates of mortality, myocardial infarction (MI), and stroke than ticagrelor under conditions of routine care of patients discharged after invasive treatment for acute coronary syndrome, with the effects being particularly pronounced in those with ST-segment elevation MI (STEMI).

METHODOLOGY:

• Researchers used data from a German insurance claims database between January 2012 and December 2021 to emulate the ISAR-REACT5 trial within routine care settings.
• They included 17,642 propensity score–matched adults (mean age, 63.1 years; 26.1% women) who were discharged after an invasive treatment strategy for acute coronary syndrome and received either ticagrelor (n = 8821) or prasugrel (n = 8821) in an outpatient setting.
• The types of coronary syndromes included STEMI, non-STEMI, and unstable angina (n = 9793, 6558, and 1291, respectively); 98.5% patients underwent percutaneous coronary intervention.
• The primary endpoint was the composite of all-cause mortality, MI, or stroke within 1 year of initiation of outpatient treatment with either of the two medications.
• The secondary endpoints included the individual components of the primary endpoint along with stent thrombosis; major bleeding was included as the safety endpoint.

TAKEAWAY:

• At the 1-year follow-up mark, individuals receiving ticagrelor showed a higher risk for the primary composite endpoint than those receiving prasugrel (hazard ratio [HR], 1.24; 95% CI, 1.12-1.37).
• Compared with prasugrel, ticagrelor was associated with higher incidences of both MI (HR, 1.20; 95% CI, 1.06 –1.36) and stroke (HR, 1.33; 95% CI, 1.02 –1.74) but not all-cause mortality.
• No significant differences in stent thrombosis and major bleeding risk were observed between the two treatment groups.
• In the STEMI subgroup, prasugrel was associated with the primary composite end point in a smaller proportion of patients than ticagrelor (6.8% vs 9.3%); however, in the non-STEMI and unstable angina subgroups, both drugs showed comparable efficacy.

IN PRACTICE:

“This study may have implications for the choice of P2Y12 receptor inhibitor for [acute coronary syndrome] components, particularly in patients with STEMI, as indirectly supported by data from other trials,” the authors of the study wrote. “Overall, this study supports guideline recommendations preferring prasugrel over ticagrelor in patients with acute MI who are intended to undergo an invasive treatment strategy,” they added.

SOURCE:

The study was led by Nils Krüger, MD, of the German Heart Center Munich, Munich, Germany. It was published online on December 02, 2024, in JAMA Network Open.

LIMITATIONS: 

The observational design of the study limited the ability to draw causal inferences due to potential confounding factors. The study could not assess the role of aspirin due to unreliable capture of the use of over-the-counter drugs. The use of a German health claims database may have restricted the generalizability of the findings to other populations and healthcare systems.

DISCLOSURES:

This study was supported by grants from the Bavarian State Ministry of Health, Care and Prevention and the Bavarian State Ministry of Science and the Arts. Additional support was provided by grants from the German Federal Ministry of Economics and Energy, the Horizon Europe Framework Programme, and other sources. Some authors reported receiving grants, personal fees, honoraria, and speaker fees from various institutions and pharmaceutical companies outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.