Prasugrel Shows No Ischemic Advantage Over Ticagrelor After PCI for ACS: Study
Sweden: In patients with acute coronary syndrome undergoing percutaneous coronary intervention, a default prasugrel-based treatment strategy did not reduce the risk of ischemic events compared with a default ticagrelor-based strategy.
The findings, published in The New England Journal of Medicine, come from a registry-based, open-label, stepped-wedge, cluster-randomized trial led by Elmir Omerovic, M.D., Ph.D., of the Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden, and colleagues. The study evaluated whether prasugrel should be preferred over ticagrelor as the standard P2Y12 inhibitor for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).
The optimal choice between these two antiplatelet agents has remained uncertain. To investigate this, researchers conducted the trial across seven regions in Sweden, which were divided into three clusters. The regions switched from a default ticagrelor strategy to a default prasugrel strategy in a randomized sequence over four 9-month periods between 2021 and 2024.
The primary outcome was a composite of death from any cause, fatal or nonfatal myocardial infarction, or fatal or nonfatal stroke within one year. Outcomes were identified through national health registries, and the analysis accounted for differences related to treatment clusters and calendar time.
A total of 17,095 patients were included. Of these, 9,444 received care under the default ticagrelor policy, while 7,651 were treated under the default prasugrel policy. The mean patient age was 69.8 years, 36.8% were aged 75 years or older, and 27.8% were women.
The following were the key findings of the trial:
- 39.4% of patients presented with ST-segment elevation myocardial infarction (STEMI), 43.7% with non-STEMI, and 16.8% with unstable angina.
- At 1 year, the primary endpoint occurred in 11.8% of patients in the ticagrelor-policy group versus 11.1% in the prasugrel-policy group (adjusted OR, 0.90; 95% CI, 0.77–1.06).
- The difference in the primary endpoint between the two strategies was not statistically significant.
- Major bleeding occurred in 4.4% of patients under the ticagrelor policy and 4.2% under the prasugrel policy.
- The prasugrel strategy was associated with a lower risk of major bleeding (adjusted OR, 0.80; 95% CI, 0.64–0.99).
- Despite the lower major bleeding risk, a default prasugrel strategy did not significantly reduce ischemic events compared with a ticagrelor-based strategy in patients with ACS undergoing PCI.
The investigators concluded that in a broad, real-world population with ACS treated with PCI, adopting prasugrel as the default P2Y12 inhibitor did not result in a lower risk of ischemic events than a ticagrelor-based strategy.
Reference:
DOI: 10.1056/NEJMoa2609057
