• Christian Valina, Franz-Josef Neumann, Maurizio Menichelli, Katharina Mayer, Jochen Wöhrle, Isabell Bernlochner, Alp Aytekin, Gert Richardt, Bernhard Witzenbichler, Dirk Sibbing, Salvatore Cassese, Dominick J Angiolillo, Sebastian Kufner, Christoph Liebetrau, Christian W Hamm, Erion Xhepa, Alexander Hapfelmeier, Hendrik B Sager, Isabel Wustrow, Michael Joner, Dietmar Trenk, Karl-Ludwig Laugwitz, Heribert Schunkert, Stefanie Schüpke, and Adnan Kastrati.
• Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
• J. Am. Coll. Cardiol. 2020 Nov 24; 76 (21): 2436-2446.

BackgroundCurrent guidelines recommend intensified platelet inhibition by prasugrel or ticagrelor in patients with unstable angina (UA) or non-ST-segment elevation (NSTE) myocardial infarction (MI).ObjectivesThis 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.MethodsThis 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.ResultsThe 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.ConclusionsIn 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).Copyright © 2020. Published by Elsevier Inc.

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