Prasugrel or ticagrelor in ACS (acute coronary syndrome) - comparative evidence

Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes

A study was undertaken because the relative merits of ticagrelor as compared with prasugrel in patients with acute coronary syndromes for whom invasive evaluation is planned are uncertain (1)

Both prasugrel and ticagrelor are suggested by options by NICE - in combination with aspirin - for use in patients with ACS (2,3)

• NICE (2) suggest that: prasugrel 10 mg in combination with aspirin is recommended as an option within its marketing authorisation, that is for preventing atherothrombotic events in adults with acute coronary syndrome (unstable angina [UA], non-ST segment elevation myocardial infarction [NSTEMI] or ST segment elevation myocardial infarction [STEMI]) having primary or delayed percutaneous coronary intervention
  
  
• NICE suggest (3) that ticagrelor, in combination with aspirin, is recommended within its marketing authorisation as an option for preventing atherothrombotic events in adults who had a myocardial infarction and who are at high risk of a further event treatment should be stopped when clinically indicated or at a maximum of 3 years

Methods (1)

• in this multicenter, randomized, open-label trial, patients were randomly assigned who presented with acute coronary syndromes and for whom invasive evaluation was planned to receive either ticagrelor or prasugrel
• primary end point was the composite of death, myocardial infarction, or stroke at 1 year
• a major secondary end point (the safety end point) was bleeding. Results A total of 4018 patients underwent randomization
  • primary end-point event occurred in 184 of 2012 patients (9.3%) in the ticagrelor group and in 137 of 2006 patients (6.9%) in the prasugrel group (hazard ratio, 1.36; 95% confidence interval [CI], 1.09 to 1.70; P=0.006).
    • respective incidences of the individual components of the primary end point in the ticagrelor group and the prasugrel group were as follows: death, 4.5% and 3.7%; myocardial infarction, 4.8% and 3.0%; and stroke, 1.1% and 1.0%. Definite or probable stent thrombosis occurred in 1.3% of patients assigned to ticagrelor and 1.0% of patients assigned to prasugrel, and definite stent thrombosis occurred in 1.1% and 0.6%, respectively
      
      
  • Major bleeding (as defined by the Bleeding Academic Research Consortium scale) was observed in 5.4% of patients in the ticagrelor group and in 4.8% of patients in the prasugrel group (hazard ratio, 1.12; 95% CI, 0.83 to 1.51; P=0.46)

The study authors concluded that, among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups (1).

Evidence showing no preferential benefit for either prasugrel or ticagrelor (4)

A more recent registry-based, open-label, stepped-wedge, cluster-randomized trial in Sweden involving adults who had undergone percutaneous coronary intervention for an acute coronary syndrome showed that:

“..In an unselected population of patients with an acute coronary syndrome who had undergone percutaneous coronary intervention, the risk of ischemic events was not lower with a default prasugrel policy than with a default ticagrelor policy..”

Reference:

1. Schupke S et al. Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes.N Engl J Med. 2019 Oct 17;381(16):1524-1534
2. NICE (July 2014).Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes
3. NICE (December 2016).Ticagrelor for preventing atherothrombotic events after myocardial infarction
4. Omerovic E et al. Prasugrel versus Ticagrelor in Acute Coronary Syndromes. NEJM August 29, 2026.