PCI complexity does not influence efficacy of ticagrelor or prasugrel in acute coronary syndrome patients

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JJ Coughlan

In patients with acute coronary syndrome treated with percutaneous coronary intervention (PCI), PCI complexity does not influence the comparative efficacy and safety of ticagrelor and prasugrel.

This is according to the findings of a post hoc analysis of patients with acute coronary syndrome, treated with PCI and randomised to either ticagrelor or prasugrel in the ISAR-REACT 5— Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment—trial, published in the journal Circulation: Cardiovascular Interventions.

According to the authors of the study, JJ Coughlan (Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany) et al, the observed comparable performance of ticagrelor and prasugrel in patients with acute coronary syndrome undergoing complex PCI may merit further investigation.

Prior to this study by Coughlan and colleagues, the comparative efficacy and safety of ticagrelor and prasugrel in patients with acute coronary syndrome undergoing complex PCI had not been defined.

ISAR-REACT 5 tested the hypothesis that ticagrelor is superior to prasugrel in reducing the primary composite endpoint of death, myocardial infarction, or stroke within 12 months in acute coronary syndrome patients intended for an invasive strategy. Findings of the study, presented at ESC 2019, found that using prasugrel rather than ticagrelor to treat patients with acute coronary syndromes is associated with a significant reduction in the incidence of death, myocardial infarction or stroke.

For the current post hoc analysis, complex PCI was defined as at least one of: multivessel PCI, ≥3 stents implanted, ≥3 lesions treated, and total stented length >60mm. The primary efficacy end point was the composite of all-cause death, myocardial infarction, or stroke; the safety endpoint was Bleeding Academic Research Consortium (BARC) types 3 to 5 bleeding. Outcomes were assessed out to 12 months after randomisation.

Coughlan and colleagues report that among the 3,377 patients treated with PCI in the ISAR-REACT 5 trial, 1,429 underwent complex PCI (ticagrelor, n=696 and prasugrel, n=733) and 1,948 underwent non-complex PCI (ticagrelor, n=980 and prasugrel, n=968).

Through their analysis, the study team found that there was no interaction between PCI complexity, assignment to either ticagrelor or prasugrel, and the primary efficacy or safety end points (p for interaction: ≥0.13).

In the complex PCI group, the primary efficacy endpoint (11% vs. 9.2%, hazard ratio: 1.19 [0.85–1.66], p=0.303) and the safety endpoint (5.2% vs. 6.1%, hazard ratio: 0.83 [0.53–1.31], p=0.419) were not statistically different in patients receiving either ticagrelor or prasugrel. In the non-complex PCI group, the primary efficacy endpoint occurred more frequently in patients assigned to ticagrelor as compared to prasugrel (8.9% vs. 5.5%, hazard ratio: 1.66 [1.18–2.34], P=0.004) without significant difference in terms of the safety endpoint (5.4% vs. 4.1%, hazard ratio: 1.41 [0.92–2.17], p=0.110).

In conclusion, Coughlan et al write that for patients with acute coronary syndrome undergoing PCI, PCI complexity does not influence the comparative efficacy and safety of ticagrelor and prasugrel.


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