Prasugrel vs. Ticagrelor in Acute Myocardial Infarction Treated with Primary Angioplasty

Outcomes did not differ between these two newer antiplatelet medications, and patients who switched to clopidogrel for economic reasons had similar outcomes.

Prasugrel and ticagrelor are class Ia antiplatelet medications recommended for ST-segment elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention. Guidelines recommend these newer drugs over the much cheaper clopidogrel if there are no contraindications. However, few studies have directly compared prasugrel and ticagrelor.

Investigators in the Czech Republic planned to randomize 2500 patients presenting with a STEMI to prasugrel or ticagrelor for 12 months, but only 1230 patients were enrolled (NCT02808767). The trial was stopped early due to “futility.” The 1-year composite outcome (risk for cardiovascular death, nonfatal MI, or stroke) was statistically similar between the groups (prasugrel, 6.6%; ticagrelor, 5.7%). No significant difference was found in the single endpoints, stent thrombosis (1.1% and 1.5%), overall mortality (4.7% and 4.2%), or major bleeding (0.9% and 0.7%).

Posthospitalization, patients could switch to clopidogrel, which (unlike the study drugs) is fully reimbursed by Czech insurance; 49% of those on prasugrel and 58% of those on ticagrelor made the switch. Cost was the predominant reason for switching (73%). Those who switched for economic reasons showed no changes in risk for ischemic or bleeding events regardless of when they switched and were generally at lower risk for major cardiovascular events than patients who continued the study medications (composite outcome: 2.5% vs. 8.5%).

Comment

In this randomized direct comparison of prasugrel and ticagrelor, no significant difference was found in ischemic events or bleeding risks. About half of all patients switched to clopidogrel during follow-up, mainly due to economic reasons, and these patients did not show worse outcomes. However, the study has limitations, including small sample size, and the switch to clopidogrel was not random but often done in patients at low ischemic risk. Clinicians should be careful when contemplating a switch to clopidogrel in higher-risk patients and those with more complex disease and multiple or proximal stents. In case of financial concerns, switching may be considered safe in lower-risk patients.

Reviewing Author

Pascal Meier, MD

Disclosures

Editorial BoardsOpen Heart

Leadership Positions in Professional SocietiesEuropean Society of Cardiology (Communication Committee); European Association of Percutaneous Cardiovascular Interventions (Chair, Web & Communication Committee)