Ticagrelor or Prasugrel?? Which antiplatelet therapy is best to treat ACS

Prasugrel and ticagrelor, novel antiplatelet agents have emerged as advanced oral antiplatelet therapy for patients with Acute Coronary Syndromes (ACS). There has been debate as to which antiplatelet agent is the best as an ACS treatment regimen.

The incidence of death, myocardial infarction (MI), or stroke was relatively lower in ACS patients receiving prasugrel than those receiving ticagrelor, revealed a study published in the New England journal.

The study was conducted by Stefanie Schupke and colleagues from German Heart Center Munich to find ou the relative merits of ticagrelor as compared with prasugrel in patients with acute coronary syndromes for whom invasive evaluation is planned. The results of the study were presented at the European Society of Cardiology (ESC) Congress 2019 in Paris where the investigators have found a limited difference between the two groups in terms of bleeding risks.

The investigators conducted a multicenter, randomized, open-label trial where they randomly assigned patients who presented with acute coronary syndromes and for whom invasive evaluation was planned to receive either ticagrelor or prasugrel. The primary endpoint was the composite of death, myocardial infarction, or stroke at 1 year. A major secondary endpoint (the safety endpoint) was bleeding.

Key results

• A total of 4018 patients underwent randomization


• A primary-end point event occurred in 184 of 2012 patients in the ticagrelor group and in 137 of 2006 patients in the prasugrel group.


• The respective incidences of the individual components of the primary endpoint 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.

"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." concluded the authors.