Key result
Prasugrel and ticagrelor are linked to ~42% lower one-year mortality vs. clopidogrel in ACS.
Why the study?
Comparative effectiveness between clopidogrel, prasugrel, and ticagrelor in patients with acute coronary syndrome remains unclear in real-world settings.
Do prasugrel and ticagrelor reduce one-year all-cause mortality compared to clopidogrel in patients with acute coronary syndrome?
Cohort (n=381,278)
Yes
Do prasugrel and ticagrelor reduce one-year all-cause mortality compared to clopidogrel in patients with acute coronary syndrome?
In a large real-world cohort of ACS patients, treatment with prasugrel or ticagrelor was associated with reduced one-year mortality compared to clopidogrel, with ticagrelor showing superior net clinical outcomes.
Prasugrel or ticagrelor was associated with lower one-year mortality than clopidogrel in ACS; extends RCT data but leaves open practice change pending randomized confirmation.
BACKGROUND: Efficient dual antiplatelet therapy is crucial in reducing adverse cardiovascular events in patients with acute coronary syndrome (ACS). Comparative effectiveness between clopidogrel, prasugrel, and ticagrelor remains unclear in real-world settings. AIMS: The objective was to evaluate one-year clinical outcomes in ACS patients treated with clopidogrel, prasugrel, or ticagrelor using data from the Polish Registry of Acute Coronary Syndromes (PL-ACS). MATERIAL AND METHODS: This retrospective cohort study analyzed 381 278 ACS patients from the PL-ACS registry from 2009 to 2022, who were treated with clopidogrel, prasugrel, or ticagrelor during hospitalization with a 12-month consistent regimen. The primary outcome was one-year all-cause mortality. Secondary outcomes included a composite of death, myocardial infarction, or stroke, and the net clinical outcome, a composite of all-cause death, myocardial infarction, stroke, and bleeding. Propensity score matching was applied to reduce confounding factors. Cox proportional hazards models were used for analysis. RESULTS: Of 381 278 ACS patients, 332 338 (87.2%) were treated with clopidogrel, 5312 (1.4%) with prasugrel, and 43 628 (11.4%) with ticagrelor. After propensity score matching, prasugrel and ticagrelor reduced mortality compared with clopidogrel (hazard ratios 1.69 and 1.72, respectively; P <0.0001). Ticagrelor also showed superior net clinical outcomes compared with both prasugrel and clopidogrel. CONCLUSIONS: This large-scale study confirms better clinical outcomes of dual antiplatelet therapy with prasugrel or ticagrelor compared to clopidogrel in ACS, with ticagrelor demonstrating superiority over prasugrel in terms of net clinical outcome. Despite the high clopidogrel usage rate in Poland, these findings support the preference for ticagrelor or prasugrel in ACS.
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Umińska et al. (2025) conducted a cohort in Acute coronary syndrome (n=381,278). Prasugrel or ticagrelor vs. Clopidogrel was evaluated on One-year all-cause mortality (HR 1.72, 95% CI 1.64-1.80, p=<0.001). Prasugrel and ticagrelor significantly reduced one-year all-cause mortality compared to clopidogrel in patients with acute coronary syndrome.
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