What Is the Best Antiplatelet Therapy in Primary Angioplasty at 12 Months?

Both prasugrel and ticagrelor showed superiority in terms of efficacy, reducing the number of major cardiovascular events at the expense of increased bleeding. This is an affordable cost, and the net clinical benefit supports these new antiplatelet therapies.

The one-year follow-up of the PRAGUE-18 study focused on a comparison of efficacy and safety between prasugrel and ticagrelor, and on the risk of ischemic events related to a strictly economically-motivated switch to clopidogrel.

Read also: Clinical and Economic Costs Compete in the De-Escalation of Antiplatelet Therapy.

The study included 1230 patients with acute myocardial infarction treated with primary angioplasty, who were randomized to prasugrel or ticagrelor with an intended treatment duration of 12 months. The primary endpoint was a composite of cardiovascular death, infarction, or stroke at one year. Since patients had to cover the costs of medication after hospital discharge, many patients decided to switch to clopidogrel despite protocol recommendation.

The primary endpoint occurred in 6.6% of patients who received prasugrel and in 5.7% of patients who received ticagrelor (hazard ratio [HR]: 1.1; 95% confidence interval [CI]: 0.7 to 1.8; p = 0.5). No significant differences were observed as regards cardiovascular death (3.3% vs. 3.0%; p = 0.769), acute myocardial infarction (3.0% vs. 2.5%; p = 0.611), all-cause death (4.7% vs. 4.2%; p=0.654), definite stent thrombosis (1.1% vs. 1.5%; p = 0.535), all bleeding (10.9% vs. 11.1%; p = 0,999), and major bleeding according to TIMI (thrombolysis in myocardial infarction) criteria (0.9% vs. 0.7%; p = 0.754).

Read also: Prasugrel vs. Ticagrelor in Diabetics with Heart Disease.

The percentage of patients who switched to clopidogrel for strictly-economic reasons was 34% for prasugrel and 44.4% for ticagrelor (p = 0.003), and this was not associated to an increase in ischemic events.

Conclusion

Prasugrel and ticagrelor are similarly effective during the first year after acute myocardial infarction with primary angioplasty. Economically-motivated post-discharge switches to clopidogrel were not associated with increased ischemic events.

Editorial

Patients who gave economic reasons for discontinuing the original protocol drug and switching to clopidogrel did not have lower spending power than patients who remained in the original schedule, but they did present lower ischemic risk. This leads us to assume certain bias. Surely, the opinion of the head cardiologists of these patients must have weighed in. Being faced with patient questioning, a cardiologist’s perception of low ischemic risk most likely supported the switch. On the contrary, high ischemic risk might have motivated cardiologists to advise patients to make an effort and keep paying the much higher price of prasugrel or ticagrelor.

Original title: One-Year Outcomes of Prasugrel Versus Ticagrelor in Acute Myocardial Infarction Treated with Primary Angioplasty: The PRAGUE-18 Study.

Reference: Zuzana Motovska et al. J Am Coll Cardiol. 2018 Jan 30;71(4):371-381.

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.