Why the study?
Current guidelines recommend intensified platelet inhibition by prasugrel or ticagrelor in UA or NSTEMI, but the relative benefits and risks of ticagrelor compared with prasugrel in NSTE-ACS with planned invasive management needed investigation.
Does ticagrelor compared to prasugrel improve clinical outcomes in patients with NSTE-ACS undergoing planned invasive management?
Population
1,179 patients assigned to ticagrelor and 1,186 assigned to prasugrel with NSTE-ACS
Comparison
Ticagrelor started immediately after randomization vs prasugrel started after coronary angiography
Design
Post hoc analysis combining prespecified subgroups of the randomized ISAR-REACT 5 trial
Follow-up
1-year follow-up
Key result
Ticagrelor resulted in a higher 1-year risk of death, MI, or stroke compared to prasugrel in patients with NSTE-ACS (8.7% vs 6.3%; HR 1.41, 95% CI 1.04-1.90).
Authors
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Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“A shift from ticagrelor to prasugrel occurred in Denmark following the findings of the ISAR-REACT 5 trial and the updated ESC guideline recommendation favoring prasugrel. In 2019, more than 99% of patients received ticagrelor; by 2022, 89% received prasugrel.”
Ticagrelor associated with higher ischemic events than prasugrel; leaves open whether this reflects confounding or a true difference.
RCT (n=2,365)
Does ticagrelor compared to prasugrel improve clinical outcomes in patients with NSTE-ACS undergoing planned invasive management?
Hazard Ratio: 1.41 (95% CI 1.04–1.9)
Absolute Event Rate: 8.7% vs 6.3%
In patients with NSTE-ACS planned for invasive management, prasugrel was superior to ticagrelor in reducing the 1-year risk of death, MI, or stroke without increasing major bleeding.
Valina et al. (2020) conducted an RCT in Non-ST-segment elevation acute coronary syndromes (NSTE-ACS) (n=2,365). Ticagrelor vs. Prasugrel was evaluated on Composite of death, MI, or stroke (HR 1.41, 95% CI 1.04 to 1.90). Ticagrelor resulted in a higher 1-year risk of death, MI, or stroke compared to prasugrel in patients with NSTE-ACS (8.7% vs 6.3%; HR 1.41, 95% CI 1.04-1.90).