The ISAR-REACT 5 showed a significant reduction in the composite outcome of death, acute myocardial infarction (AMI), or stroke when using prasugrel vs. ticagrelor in patients with acute coronary syndrome (ACS), mainly at the expense of an AMI reduction.
While this study changed clinical practice, it has stirred some criticism regarding certain methodological aspects, such as its open design, baseline differences in pretreatment, or the cross-over (20% of patients changed their antiplatelet therapy at hospital discharge). Based on these results, the latest guidelines for non-ST-segment elevation ACS from the European Society of Cardiology recommended using prasugrel over ticagrelor.
There are few papers comparing these P2Y12 inhibitors head-to-head, particularly in patients without ACS. According to the PINNAPLE Registry from the United States, approximately 34% of patients without ACS who underwent a percutaneous coronary intervention (PCI) received ticagrelor or prasugrel. The aim of this study done by Koshy et al. was to compare the efficacy and safety of prasugrel vs. ticagrelor in a contemporaneous cohort of real-world patients who underwent PCI (real world data).
The study included consecutive patients who underwent PCI—for ACS or chronic coronary syndrome (CCS) fit for dual antiplatelet therapy—in a tertiary center in the United States (Mount Sinai Hospital). Patients with cardiogenic shock or using oral anticoagulant agents were excluded.
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Maintenance therapy with prasugrel was 5 mg/day for most cases, except patients weighing ≥100 kg or with 3 stents in the same vessel, who received 10 mg/day.
The primary endpoint (PEP) was a composite of all-cause mortality and AMI at one year. Secondary endpoints were vessel revascularization rate, stent thrombosis, bleeding, stroke, and individual components of the PEP.
The study included 3858 patients with a mean age of 62±10 years; 22.7% of them were female. The most commonly used P2Y12 inhibitor was ticagrelor (71.8%) and the most frequent clinical scenario was CCS (48.4%) followed by unstable angina (26.7%) and non-ST-segment acute coronary syndrome (NSTEACS; 17.5%).
No significant differences were evident in the PEP: 3.3% in patients using ticagrelor vs. 3.1% of patients taking prasugrel (adjusted hazard ratio [HR]: 0.88; 95% confidence interval [CI]: 0.54-1.43; p = 0.59). No significant differences were observed in stroke or stent thrombosis (HR: 1.54; 95% CI: 0.49-4.80; p = 0.456). When analyzing the rate of revascularization at one year, a lower event rate was observed with ticagrelor (adjusted HR: 0.71; 95% CI: 0.55-0-91; p = 0.007), something that remained true for the subgroup of patients with ACS.
CONCLUSIONS
In this contemporary study, which includes patients with ACS and with CCS, there were no differences in terms of PEP incidence, taking into account the limitations of the observational nature of the study. In turn, there was a lower rate of new revascularization with ticagrelor, something that differs from previous studies. This could be partly associated with the baseline difference in the investigated branches (prasugrel was prescribed to patients with previous revascularization or myocardial revascularization surgery). This encourages us to continue the search for randomized studies that evaluate clinical scenarios other than ACS.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Ticagrelor vs Prasugrel in a Contemporary Real-World Cohort Undergoing Percutaneous Coronary Intervention.
Reference: Koshy, Anoop N et al. “Ticagrelor vs Prasugrel in a Contemporary Real-World Cohort Undergoing Percutaneous Coronary Intervention.” JACC. Cardiovascular interventions vol. 15,22 (2022): 2270-2280. doi:10.1016/j.jcin.2022.09.021.
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