Prasugrel tops ticagrelor for reducing risk of ischaemic events in ACS patients with prior MI

Prasugrel appears to better protect against the risk of ischaemic events in patients with acute coronary syndrome (ACS) and prior myocardial infarction (MI) as compared with ticagrelor, without a trade-off in bleeding, a study has found.

The study involved 4,015 ACS patients who were scheduled to undergo an invasive strategy and randomized to ticagrelor or prasugrel in the ISAR‐REACT (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) 5 trial.

Of the patients, 631 (15.7 percent) had prior MI. This group of patients were more likely to be older, have diabetes, hypercholesterolemia, prior coronary revascularization, higher body mass index, unstable angina, and multivessel disease, among others, compared with the group of patients without prior MI (control). A total of 4,001 patients (99.7 percent) overall underwent coronary angiography. There were 90 patients who did not complete the 12-month follow-up.

The primary endpoint of the composite of 1‐year all‐cause death, MI, or stroke occurred with greater frequency in the prior MI group than in the control group (12.6 percent vs 7.2 percent; hazard ratio [HR], 1.78, 95 percent confidence interval [CI], 1.38–2.29).

Meanwhile, the secondary safety endpoint of the composite of 1‐year Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding was similar regardless of prior MI (5.8 percent vs 5.7 percent; HR, 1.02, 95 percent CI, 0.71–1.45).

Compared with prasugrel, ticagrelor was associated with a higher frequency of the primary endpoint both in the prior MI group (15.4 percent vs 9.9 percent; hazard ratio [HR], 1.62, 95 percent CI, 1.03–2.55) and the control group (8.1 percent vs 6.4 percent; HR, 1.28, 95 percent CI, 0.99–1.65; p=0.37 for interaction).

In terms of the secondary safety endpoint, BARC type 3 to 5 bleeding occurred in 5.4 percent of patients with ticagrelor vs 3.8 percent with prasugrel in the prior MI group (HR, 1.28, 95 percent CI, 0.56–2.91), as well as in 5.7 percent vs 5.1 percent, respectively, in the control group (HR, 1.13, 95 percent CI, 0.82–1.55; p=0.79 for interaction).