ESC 2019 | ISAR-REACT 5 | Which Is Better in ACS, Prasugrel or Ticagrelor?

Courtesy of Dr. Carlos Fava.

The benefit of dual antiplatelet therapy in acute coronary syndromes (ACS) has been proven long ago, and both prasugrel and ticagrelor have offered best results than clopidogrel. However, nowadays, it is unclear which of them is superior in the long term, taking into account the fact that one starts to act before the other.

This randomized study included 2012 patients who received ticagrelor and 2006 who received prasugrel plus aspirin.

The primary endpoint was all-cause death, acute myocardial infarction, or stroke after a 1-year follow-up.

Groups were similar: the mean age was 64 years, 22% of patients had diabetes, 70% had hypertension, 15% had an infarction, 22% had angioplasty, and 6% had myocardial revascularization surgery.

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The diagnosis upon admission was ST-segment elevation acute myocardial infarction (STEMI) in 41.1% of cases, non-ST-segment elevation acute myocardial infarction (NSTEMI) in 46.2% of cases, and unstable angina in 12% of cases. Notably, 35% of patients had received aspirin before admission.

After a 1-year follow-up, the primary endpoint was 9.1% for ticagrelor and 6.8% for prasugrel (hazard ratio: 1.36; 95% confidence interval [CI]: 1.09 to 1.70; P = 0.006). There were no differences regarding the composite of cardiovascular death, acute myocardial infarction, and stroke: 8.1% vs. 6.3% (hazard ratio: 1.32; 95% CI: 1.04 to 1.66).

There were no differences as regards acute myocardial infarction, stroke, definite or probable thrombosis, or major bleeding (BARC 3-5).


Among patients with acute coronary syndromes with or without ST-segment elevation, the incidence of death, infarction, or stroke was significantly lower among subjects who received prasugrel compared with those who received ticagrelor, and there were no differences regarding major bleeding.

Courtesy of Dr. Carlos Fava.

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Original Title: Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. ISAR-REACT 5.

Reference: S. Schüpke, F.-J. Neumann, M. Menichelli, K, et al. N Eng J Med, Sept 1, 2019 DOI: 10.1056/NEJMoa1908973.

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