Analysis of STEMI patients finds little difference between prasugrel and ticagrelor after PCI

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A subgroup analysis of the ISAR REACT-5—Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5—trial has found that among patients with ST-segment–elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) receiving either prasugrel or ticagrelor, there was no significant difference in combined rates of death, myocardial infarction, or stroke at one year.

The analysis, authored by Alp Aytekin (Universität München, Munich, Germany) and colleagues, published in Circulation, also concluded that ticagrelor was associated with a significant increase in the risk for recurrent myocardial infarction.

In the study, Aytekin and colleagues note that data on the comparative efficacy and safety of ticagrelor versus prasugrel in patients with STEMI undergoing primary PCI are limited.

The pre-specified subgroup analysis included 1,653 patients with STEMI randomised to receive ticagrelor or prasugrel in the setting of the ISAR REACT-5 trial. The primary endpoint was the incidence of death, myocardial infarction, or stroke at one year after randomisation. The secondary endpoint was the incidence of bleeding defined as BARC (Bleeding Academic Research Consortium) type 3‒5 bleeding at one year after randomisation.

Detailing the results, Aytekin and colleagues note that the primary endpoint occurred in 83 patients (10.1%) in the ticagrelor group and in 64 patients (7.9%) in the prasugrel group (hazard ratio, 1.31 [95% CI, 0.95–1.82]; P=0.10). One-year incidence of all-cause death (4.9% versus 4.7%; P=0.83), stroke (1.3% versus 1.0%; P=0.46), and definite stent thrombosis (1.8% versus 1.0%; P=0.15) did not differ significantly in patients assigned to ticagrelor or prasugrel, they note.

One-year incidence of myocardial infarction (5.3% versus 2.8%; hazard ratio, 1.95 [95% CI, 1.18–3.23]; P=0.010) was higher with ticagrelor than with prasugrel, the authors note, adding that BARC type 3‒5 bleeding occurred in 46 patients (6.1%) in the ticagrelor group and in 39 patients (5.1%) in the prasugrel group (hazard ratio, 1.22 [95% CI, 0.80–1.87]; P=0.36).

In their conclusion, the authors state: “In patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention, there was no significant difference in the primary endpoint between prasugrel and ticagrelor. Ticagrelor was associated with a significant increase in the risk for recurrent myocardial infarction.”


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