SOLACI | Latin American Society of Interventional Cardiology

When we have to choose between two potent P2Y12 receptor inhibitors for a patient undergoing ACS with a planned invasive strategy, kidney function should not interfere in this decision.

The main findings of this study were that prasugrel has lower risk of all cause death, MI or stroke, and also had a similar risk of bleeding compared against ticagrelor. These findings were consistent with those of low and intermediate risk patients or high glomerular filtration.

These findings were presented during the ESC 2021 scientific sessions and were simultaneously published in JACC: Cardiovascular Interventions.

Patients with altered kidney function are challenging for multiple reasons: on the one hand, they present higher ischemic risk and on the one hand, a higher risk of bleeding, given drug pharmacokinetics.

For this analysis, the authors divided 4,012 participants according to glomerular filtration into 3 groups: low (<60 mL/min/1.73; m2; 760 patients), intermediate (60 to 90 mL/min/1.73 m2; 1968 patients) and high (>90 mL/min/1.73 m2; 1284 patients).

As expected, the worse the glomerular filtration, the bigger the number of events, both ischemic and hemorrhagic.

However, this did not affect the relative efficacy of prasugrel. Moreover, its biggest advantage was in patients with worse glomerular filtration.

Specifically, in this last subgroup, the rate of all cause death, MI or stroke was significantly higher in patients receiving ticagrelor vs prasugrel (20.5% vs 14.7%; HR 1.47; CI 95% 1.04 to 2.08), with no cost in bleeding BARC 3-5 (10.4% vs 8.4%; HR 1.24; CI 95% 0.73-2.09).

After a few years of absolute dominion of ticagrelor, several studies have slowly brought back prasugrel and clopidogrel to the current clinical arena.

Original Title: Ticagrelor or prasugrel in patients with acute coronary syndrome in relation to estimated glomerular filtration rate.

Reference: Wöhrle J. J Am Coll Cardiol Intv. 2021; Epub ahead of print.