Ticagrelor or Prasugrel in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes

Abstract

Background: Current guidelines recommend intensified platelet inhibition by prasugrel or ticagrelor in patients with unstable angina (UA) or non-ST-segment elevation (NSTE) myocardial infarction (MI).

Objectives: This study sought to investigate 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: This post hoc analysis combines the pre-specified subgroups of UA and 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.

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 to 1.90). The HR for all-cause death was 1.43 (95% CI: 0.93 to 2.21) and that for MI 1.43 (95% CI: 0.94 to 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 to 1.65). Landmark analysis revealed persistence of the efficacy advantage with prasugrel after the first month.

Conclusions: In patients with NSTE-ACS, we found that prasugrel was superior to ticagrelor in reducing the combined 1-year risk of death, MI, and stroke without increasing the risk of bleeding. Due to the post hoc nature of the analysis, these findings need confirmation by further studies. (Prospective, Randomized Trial of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome; NCT01944800).

Keywords: mortality; non-ST-segment elevation acute coronary syndrome; percutaneous coronary intervention; prasugrel; ticagrelor.

Conflict of interest statement

Author Relationship With Industry Dr. Neumann has received lecture fees, paid to his institution, from Amgen, Daiichi-Sankyo, Novartis, and Ferrer; has received lecture fees, paid to his institution, and consulting fees, paid to his institution, from AstraZeneca and Boehringer Ingelheim; has received grant support and lecture fees, paid to his institution, from Pfizer, Biotronic, Edwards Lifesciences, Bayer HealthCare, and GlaxoSmithKline; and has received grant support from Medtronic, Abbott Vascular, and Boston Scientific. Dr. Sibbing has received personal fees from Bayer AG, Sanofi, AstraZeneca, Pfizer, Ferrer, and Daiichi-Sankyo; and has received grants and personal fees from Roche Diagnostics. Dr. Angiolillo has received consulting fees or honoraria from Abbott, Amgen, Aralez, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, PhaseBio, PLx Pharma, Pfizer, Sanofi, and The Medicines Company; has received payments for participation in review activities from CeloNova and St. Jude Medical; and his institution has received research grants from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Idorsia, Janssen, Matsutani Chemical Industry Co., Merck, Novartis, Osprey Medical, Renal Guard Solutions, and the Scott R. MacKenzie Foundation. Dr. Liebetrau has received consulting fees or honoraria from AstraZeneca, Bayer, Berlin Chemie, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi-Sankyo, Pfizer, and Thermo Fisher; and has received research grants from Deutsche Herzstiftung, Kerckhoff-Stiftung, and Kühl-Stiftung outside the submitted work. Dr. Liebetrau’s institution has received payments for participation in clinical study programs from Abbott, AstraZeneca, Bayer, Biosensors, Boston Scientific, Daiichi-Sankyo, and Neovasc. Dr. Hamm has received Advisory Board and speaker fees from AstraZeneca and Daiichi-Sankyo. Dr. Sager has received funding from the European Research Council under the European Union’s Horizon 2020 Research and Innovation Programme (STRATO), the Else-Kröner-Fresenius-Stiftung, the Deutsche Herzstiftung, and the Deutsche Forschungsgemeinschaft. Dr. Joner has received personal fees from Biotronik, Orbus Neich, Boston Scientific, Edwards, AstraZeneca, and Recor; and has received grants from Boston Scientific, Edwards, and Amgen. Dr. Trenk has received consulting fees or honoraria from Amgen, AstraZeneca, Bayer, Berlin Chemie, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi-Sankyo, Ferrer, Pfizer, and Sanofi; and has received research grants from Deutsche Herzstiftung and PharmCompNet Baden-Wuerttemberg: Kompetenznetzwerk Pharmakologie Baden-Wuerttemberg outside the submitted work. Dr. Trenk’s institution has received payments for participation in clinical study programs from Amgen, AstraZeneca, Bayer, Daiichi-Sankyo, Doasense, Esperion, Idorsia, and Otsuka. Dr. Schunkert has received personal fees from Merck Sharp & Dohme, Amgen, Bayer Vital GmbH, Boehringer Ingelheim, Daiichi-Sankyo, Novartis, Servier, Brahms, Bristol Myers Squibb, Medtronic, Sanofi, Synlab, Pfizer, and Vifor; and has received grants and personal fees from AstraZeneca. Dr. Schüpke has received grants from the DZHK (German Center for Cardiovascular Research) and the Else Kröner-Fresenius-Stiftung; has received consulting fees from Bayer Vital GmbH; and has received lecture fees from Daiichi-Sankyo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Copyright © 2020. Published by Elsevier Inc.