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Original Investigation
June 30, 2021

Ticagrelor or Prasugrel for Patients With Acute Coronary Syndrome Treated With Percutaneous Coronary Intervention: A Prespecified Subgroup Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
  • 2School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
  • 3Department of Cardiology, Ospedale Fabrizio Spaziani, Frosinone, Italy
  • 4Department of Cardiology, Medical Campus Lake Constance, Friedrichshafen, Germany
  • 5Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany
  • 6German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
  • 7Department of Cardiology and Pneumology, Helios Amper-Klinikum Dachau, Dachau, Germany
  • 8Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
  • 9Department of Cardiology, Klinik der Universität München, Ludwig–Maximilians–University, Munich, Germany
  • 10Division of Cardiology, University of Florida College of Medicine, Jacksonville
  • 11Department of Cardiology, Heart Center Bad Segeberg, Bad Segeberg, Germany
  • 12Heart Center, Campus Kerckhoff of Justus-fLiebig-University, Giessen, Germany
  • 13Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich School of Medicine, Munich, Germany
  • 14School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
JAMA Cardiol. 2021;6(10):1121-1129. doi:10.1001/jamacardio.2021.2228
Key Points

Question  Is a ticagrelor-based or prasugrel hydrochloride–based strategy superior for patients with acute coronary syndrome treated with percutaneous coronary intervention?

Findings  In this prespecified subgroup analysis of a randomized clinical trial, among patients with acute coronary syndrome who underwent percutaneous coronary intervention, the composite end point of all-cause death, myocardial infarction, or stroke occurred less frequently for patients who received prasugrel compared with ticagrelor.

Meaning  These results suggest that, for patients with acute coronary syndrome who undergo percutaneous coronary intervention, a prasugrel-based strategy is superior to a ticagrelor-based strategy.

Abstract

Importance  It is unclear whether ticagrelor or prasugrel hydrochloride is superior for patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI).

Objective  To assess the safety and efficacy of ticagrelor vs prasugrel for patients with ACS treated with PCI.

Design, Setting, and Participants  A prespecified analysis was performed of a postrandomization subgroup of 3377 patients who presented with ACS and were treated with PCI in the investigator-initiated, multicenter, phase 4, open-label Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5 randomized clinical trial, conducted from September 1, 2013, to February 28, 2018. Statistical analysis was performed from September 1, 2020, to January 30, 2021. Analysis was performed according to the intention-to-treat principle.

Interventions  Patients were randomly assigned to a ticagrelor-based or prasugrel-based strategy. This analysis focuses on the subgroup of patients who underwent PCI that was formed after randomization.

Main Outcomes and Measures  The primary end point was a composite consisting of all-cause death, myocardial infarction, or stroke at 12 months. The safety end point was Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding.

Results  The ticagrelor group comprised 1676 patients (1323 men [78.9%]; mean [SD] age, 64.4 [12.0] years), and the prasugrel group comprised 1701 patients (1341 men [78.8%]; mean [SD] age, 64.7 [12.0] years). The primary end point occurred for 162 patients (9.8%) in the ticagrelor group and 120 patients (7.1%) in the prasugrel group (hazard ratio [HR], 1.41; 95% CI, 1.11-1.78; P = .005). Myocardial infarction occurred in 88 patients (5.3%) in the ticagrelor group compared with 55 patients (3.8%) in the prasugrel group (HR, 1.67; 95% CI, 1.19-2.34; P = .003). The safety end point, BARC type 3 to 5 bleeding, occurred in 84 of 1672 patients (5.3%) in the ticagrelor group and 78 of 1680 patients (4.9%) in the prasugrel group (HR; 1.10; 95% CI, 0.81-1.50; P = .54).

Conclusions and Relevance  Among patients presenting with ACS who were treated with PCI, the incidence of the primary composite end point occurred less frequently for patients who received prasugrel compared with those who received ticagrelor. The incidence of bleeding events was comparable between the 2 groups. These results suggest that, for patients presenting with ACS who undergo PCI, a prasugrel-based strategy is superior to a ticagrelor-based strategy. However, because these observations are based on a postrandomization subgroup, these findings should be regarded as hypothesis generating and dedicated randomized clinical trials may be warranted to confirm these findings.

Trial Registration  ClinicalTrials.gov Identifier: NCT01944800

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