Ticagrelor and prasugrel have similar rates of myocardial infarction (MI) and death at 1 year after percutaneous coronary intervention (PCI) for either acute coronary syndrome (ACS) or chronic coronary syndrome (CCS), according to a real-world analysis of data from a single center.
Anoop Koshy, MBBS, PhD, of the Icahn School of Medicine at Mount Sinai in New York and the University of Melbourne, Australia, and colleagues reported these findings in a manuscript published Monday online and in the Nov. 28 issue of JACC: Cardiovascular Interventions.
Both ticagrelor and prasugrel are supported in the guidelines for use after PCI for ACS and receive a Class IIb recommendation for PCI after CCS with high lesion complexity. Head-to-head comparisons of ticagrelor and prasugrel are limited. ISAR-REACT V, a pragmatic trial, found that prasugrel was superior to ticagrelor is reducing ischemia-related events without increasing bleeding. Real-world data comparing the two drugs remain sparse.
Koshy and colleagues set out to compare the efficacy and safety of ticagrelor and prasugrel among consecutive patients undergoing PCI at Mount Sinai Hospital. The primary endpoint was the composite of death and MI, and secondary outcomes included rates of bleeding, stroke, and target vessel revascularization at 1 year.
Overall, 3,858 patients were included in the study (ticagrelor: n=2,771; prasugrel: n=1,087), and a plurality (48.4%) underwent PCI in the context of CCS. Patients prescribed ticagrelor were more often female, had history of stroke, and had ACS. Patients prescribed prasugrel were more often white and had a higher prevalence of prior revascularization. There was no difference in the primary composite endpoint (ticagrelor vs prasugrel: 3.3% vs 3.1%; hazard ratio [HR]: 0.88; 95% confidence interval [CI]: 0.54-1.43; P=0.59) while the rate of target vessel revascularization was significantly lower in the ticagrelor cohort (9.3% vs 14.0%; adjusted HR: 0.71; 95% CI: 0.55-0.91; P=0.007), and there were no differences in stroke or bleeding. The results were consistent in patients with CCS and ACS without interaction. This analysis was confirmed in multivariable analysis and propensity-score stratification analysis
Jochen Wöhrle, MD and Julia Seeger, MD of the Medical Campus Lake Constance, Friedrichshafen, Germany, wrote an editorial comment. The editorialists commented that potent P2Y12 inhibitor use is becoming more common among CCS patients. They also emphasized that lesion complexity was high in this study; 78% were type B2/C lesions, 25% were bifurcation lesions, 9% were chronic total occlusions, and 46% were complex lesions. With regard to future need for investigation, they wrote: “A prospective trial comparing both potent P2Y12 inhibitors in a PCI patient population with CCS and a high ischemic risk is eagerly awaited.”
Koshy AN, Giustino G, Sartori S, et al. Ticagrelor vs Prasugrel in a Contemporary Real-World Cohort Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv. 2022;15:2270–2280.
Wöhrle J, Seeger J. Prasugrel and Ticagrelor Treatment: Among Patients With ACS Is There a Need for a New Randomized Trial? JACC Cardiovasc Interv. 2022;15:2281–2283.
Image Credit: andrey_orlov – stock.adobe.com