Prasugrel versus Ticagrelor in Acute Coronary Syndromes.
Elmir Omerovic, Sasha Koul, Jonas Andersson et al.
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In 30 seconds
This registry-based, open-label, stepped-wedge cluster-randomized trial compared default prasugrel and ticagrelor policies among adults in Sweden who underwent percutaneous coronary intervention for acute coronary syndrome. Across seven regions, 17,095 patients received care under one of the policies. At 1 year, the composite of death, myocardial infarction, or stroke occurred in 11.1% under the prasugrel policy and 11.8% under the ticagrelor policy (adjusted odds ratio, 0.90; 95% CI, 0.77 to 1.06). The trial found no lower risk of ischemic events with a default prasugrel policy.
Key findings
- At 1 year, primary end-point events occurred in 11.1% with the prasugrel policy and 11.8% with the ticagrelor policy (adjusted odds ratio, 0.90; 95% CI, 0.77 to 1.06).
- Major bleeding occurred in 4.2% under the prasugrel policy and 4.4% under the ticagrelor policy (adjusted odds ratio, 0.80; 95% CI, 0.64 to 0.99).
- The trial enrolled 17,095 patients across seven Swedish regions; 36.8% were at least 75 years old and 27.8% were female.
Why it matters
The comparison addresses uncertainty about which P2Y12 inhibitor to use as the default after PCI for acute coronary syndrome. In this large, unselected population, the prasugrel policy did not produce a lower rate of the composite ischemic outcome at 1 year. The findings help frame policy-level comparisons while leaving individual treatment decisions to clinical context.
What to keep in mind
The trial compared regional default-treatment policies in an open-label, stepped-wedge design, rather than assigning each patient individually to a drug.