Ticagrelor vs Prasugrel Post PCI in STEMI by Ahmed Magdy

New anti-platelets were successful in the treatment of ACS in large landmark clinical trials namely PLATO on ticagrelor and TIMI 38 on prasugrel, to reduce cardiovascular events compared to clopidogrel and were recommended by recent STEMI guidelines to be preferred for patients undergoing primary PCI. Prasugrel was deemed to be avoided in patients with low body weight less than 65 kg and elderly above 75 years or those with recent stroke or bleeding. Those three sub groups were excluded in PRAGUE-18 study by Motovska Z, Hlinomaz O, Kala P, et al who compared Prasugrel (n = 634) and Ticagrelor(n = 596) in patients with STEMI undergoing primary PCI and 5% who represented very high risk non-STEMI undergoing emergent PCI. They also excluded Administration of clopidogrel ≥300 mg before randomization. They were followed for 30 days; 1 year. 20% were diabetics, 23% were females.

The results published and announced in November 2017 showed similarity in primary outcome. The incidence of death, reinfarction, urgent target vessel revascularization, stroke, serious bleeding requiring transfusion, or prolonged hospitalization at 7 days, occurred in 4.0% of the Prasugrel group versus 4.1% of the Ticagrelor group (p = 0.94).  Secondary outcomes as well were similar, cardiovascular death, nonfatal MI, or stroke at 30 days: 2.7% versus 2.5% (p = 0.86),TIMI major bleeding at 30 days: 0.6% versus 0.7% (p = 0.85),Cardiovascular death, nonfatal MI, or stroke at 1 year: 6.6% versus 5.7% (p = 0.50), respectively, for prasugrel versus ticagrelor.

Interpretation: Among patients with STEMI undergoing primary PCI, if you exclude the risky subgroups for prasugrel, it has similar efficacy and bleeding compared to ticagrelor. Similar ischemic events were noted at 7 days and 1 year. Among such patients, the use of either agent is acceptable. This emphasizes the importance of selecting the appropriate patient and or agent when utilizing the new anti-platelets to get the best results.

A full coverage of anti-platelets and anti-coagulants as well as cardiac pharmaco-intervention therapy, guidelines and evidence based strategies will be discussed in comprehensive sessions during the C3 Conference June 17-20, 2018 (www.c3conference.net) in Orlando.


Motovska Z, Hlinomaz O, Kala P, et al., on behalf of the PRAGUE-18 Study Group. 1-Year Outcomes of Patients Undergoing Primary Angioplasty for Myocardial Infarction Treated With Prasugrel Versus Ticagrelor. J Am Coll Cardiol 2018;71:371-81