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Ticagrelor or Prasugrel in Patients With NSTE-ACS
Quick Takes
- This post hoc study reports that in patients with NSTE-ACS managed invasively, the prasugrel regimen was associated with reduced composite risk of death, MI, and stroke as compared with the ticagrelor regimen during 1-year follow-up and was not associated with an increased risk of bleeding.
- Overall, these findings suggest prasugrel as the treatment of choice in this setting, unless contraindications such as previous stroke or intolerance.
- Given the post hoc nature of the analysis and the open-label design of the ISAR-REACT 5 trial, these findings should be considered hypothesis generating.
Study Questions:
What are the benefits and risks of ticagrelor as compared with prasugrel in patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) and planned invasive management?
Methods:
The investigators performed a post hoc analysis combining the prespecified subgroups of unstable angina and NSTE myocardial infarction (NSTEMI) of the randomized ISAR-REACT 5 trial. It included 1,179 patients assigned to ticagrelor and 1,186 assigned to prasugrel. Ticagrelor was started immediately after randomization and prasugrel after coronary angiography. The primary endpoint was a composite of death, MI, or stroke during 1-year follow-up, and the safety endpoint was Bleeding Academic Research Consortium class 3–5. Kaplan-Meier curves were used for visualizing cumulative outcomes in the two groups and Cox proportional hazard models were used to estimate effect sizes for the study treatment group with the participating center as covariate.
Results:
The primary endpoint was reached in 101 (8.7%) patients in the ticagrelor and in 73 (6.3%) patients in the prasugrel group (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.04-1.90). The HR for all-cause death was 1.43 (95% CI, 0.93-2.21) and for was MI 1.43 (95% CI, 0.94-2.19). The safety endpoint occurred in 49 (5.2%) patients in the ticagrelor and in 41 (4.7%) patients in the prasugrel group (HR, 1.09; 95% CI, 0.72-1.65). Landmark analysis revealed persistence of the efficacy advantage with prasugrel after the first month.
Conclusions:
The authors concluded that in patients with NSTE-ACS, prasugrel was superior to ticagrelor in reducing the combined 1-year risk of death, MI, and stroke without increasing the risk of bleeding.
Perspective:
This post hoc study reports that in patients with NSTE-ACS managed invasively, the prasugrel regimen was associated with reduced composite risk of death, MI, and stroke as compared with the ticagrelor regimen during 1-year follow-up and was not associated with an increased risk of bleeding. Furthermore, this analysis does not suggest a relevant advantage in efficacy by pretreatment with ticagrelor. Overall, these findings suggest prasugrel as the treatment of choice in this setting, unless there are contraindications such as previous stroke or intolerance. Given the post hoc nature of the analysis, these findings should not be regarded as conclusive and considered hypothesis generating.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging, Vascular Medicine
Keywords: Acute Coronary Syndrome, Angina, Unstable, Coronary Angiography, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Purinergic P2Y Receptor Antagonists, Risk Assessment, Secondary Prevention, Stroke
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