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Ticagrelor or Prasugrel in STEMI Patients Undergoing PPCI
Quick Takes
- Among STEMI patients undergoing primary PCI, ticagrelor and prasugrel are associated with similar composite clinical (death, MI, stroke) and bleeding (BARC 3, 4, and 5) outcomes.
- Ticagrelor is associated with higher rates of recurrent MI at 12 months.
- Findings support taking a personalized approach in choosing a P2Y12 inhibitor based on individual patients’ clinical and bleeding risk.
Study Questions:
What is the safety and efficacy of ticagrelor compared to prasugrel among patients with ST-segment elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PPCI)?
Methods:
In this prespecified subgroup analysis, 1,653 patients with STEMI were randomized to receive ticagrelor or prasugrel in the setting of the ISAR-REACT 5 trial. The primary endpoint was the incidence of death, myocardial infarction (MI), or stroke at 1 year after randomization. The secondary endpoint was the incidence of bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3-5 bleeding at 1 year after randomization.
Results:
The primary endpoint occurred in 83 patients (10.1%) in the ticagrelor group and in 64 patients (7.9%) in the prasugrel group (hazard ratio [HR], 1.31; 95% confidence interval [CI], 0.95-1.82; p = 0.10). One-year incidence of all-cause death (4.9% vs. 4.7%; p = 0.83), stroke (1.3% vs. 1.0%; p = 0.46), and definite stent thrombosis (1.8% vs. 1.0%; p = 0.15) did not differ significantly in patients assigned to ticagrelor or prasugrel. One-year incidence of MI (5.3% vs. 2.8%; HR, 1.95; 95% CI, 1.18-3.23; p = 0.010) was higher with ticagrelor than with prasugrel. BARC type 3-5 bleeding occurred in 46 patients (6.1%) in the ticagrelor group and in 39 patients (5.1%) in the prasugrel group (HR, 1.22; 95% CI, 0.80-1.87; p = 0.36).
Conclusions:
In this cohort of patients with STEMI undergoing PPCI, there was no significant difference in the primary endpoints between prasugrel and ticagrelor. Ticagrelor was associated with a significant increase in the risk for recurrent MI.
Perspective:
This is a subgroup analysis of predominantly male patients with STEMI undergoing PPCI from the ISAR-REACT 5 trial. The original trial showed superiority of prasugrel over ticagrelor among all patients with acute coronary syndrome undergoing PCI. This prespecified analysis of STEMI patients shows no significant difference in the safety or composite efficacy (death, MI, stroke) of prasugrel over ticagrelor, although the authors note that rates of recurrent MI at 12 months were higher in the ticagrelor group compared to prasugrel. This finding should be interpreted with caution given that 12.5% of patients in the ticagrelor group had discontinued study medication (compared to 9.5% in the prasugrel group) and fewer patients in the ticagrelor group were discharged on aspirin and statin therapy.
Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Anticoagulation Management and ACS, Interventions and ACS, Interventions and Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, Anticoagulants, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Purinergic P2Y Receptor Antagonists, ST Elevation Myocardial Infarction, Stents, Stroke, Thrombosis
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