We are still asking the same question: ticagrelor or prasugrel? With narrow margins between these drugs in terms of efficacy and bleeding, it is difficult to decide which to prescribe.
While it has certain methodological limitations, this research published in JAMA seems to clarify the picture at least for patients with acute coronary syndromes who undergo angioplasty.
This pre-specified post-randomization analysis included a subgroup of 3377 patients with acute coronary syndrome. Patients were randomized to receive ticagrelor or prasugrel prior to angioplasty.
The primary endpoint was a composite of all-cause mortality, myocardial infarction, or stroke at 12 months. The primary safety endpoint was BARC 3-5 bleeding.
Both arms, ticagrelor (n = 1676) and prasugrel (n = 1701), were well matched for clinical characteristics.
The primary endpoint occurred in 9.8% of patients in the ticagrelor arm vs. 7.1% in the prasugrel arm (hazard ratio: 1.41; 95% confidence interval: 1.11-1.78; p = 0.005). Prasugrel was also better when considering infarction only (5.3% vs. 3.8%, p = 0.03)
Researchers expected ticagrelor to perhaps compensate for thrombotic events due to its historical safety as regards bleeding (carried over from the PLATO study), but this was not the case: both drugs had similar rates of BARC 3-5 bleeding (5.3% vs 4.9%; p = 0.54).
In patients with acute coronary syndrome who undergo angioplasty, the incidence of the primary endpoint was less frequent among those who received prasugrel, with no incidence on bleeding.
This places prasugrel as a superior strategy, although not definitely; observations are from a post-randomization subgroup, so further dedicated studies are required to reach a final conclusion.
Original Title: Ticagrelor or Prasugrel for Patients With Acute Coronary Syndrome Treated With Percutaneous Coronary Intervention. A Prespecified Subgroup Analysis of a Randomized Clinical Trial.
Reference: J. J. Coughlan et al. JAMA Cardiol. 2021 Jun 30. Online ahead of print. doi: 10.1001/jamacardio.2021.2228.