ESC 2019 — ACS with planned invasive evaluation: prasugrel bests ticagrelor

  • Emily Willingham, PhD
  • Conference Reports
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  • Patients with acute coronary syndrome (ACS) with ST-segment elevation myocardial infarction (STE[MI]) or not (NSTEMI) and for whom invasive evaluation is planned have reduced 1-year mortality/MI/stroke with prasugrel vs ticagrelor.

Why this matters

  • Both prasugrel and ticagrelor have class I recommendation for ACS, STEMI, or NSTEMI, but the relative 1-year outcomes with these drugs for patients planned for invasive evaluation are not clear.
  • The authors note that this trial not only compared 2 drugs but also 2 antiplatelet treatment strategies (pretreatment with ticagrelor vs deferred prasugrel loading after establishing coronary anatomy in NSTEMI).
  • In an unofficial Twitter poll during the conference, 51% of 158 respondents said prasugrel would now be their first choice, 15% said it would be ticagrelor, and 35% said they would individualize treatment.


  • 1-year any-cause mortality/MI/stroke rates with ticagrelor vs prasugrel:
    • 9.3% vs 6.9%.
    • HR, 1.36 (95% CI, 1.09-1.70; P=.006).
  • Similar outcomes for composite of cardiovascular death/MI/stroke.
  • MI drove composite results.
  • Major bleeding was similar between groups.
  • At 1 year, 15.2% with ticagrelor and 12.5% with prasugrel had discontinued therapy (P=.03). 

Study design

  • Multicenter (21 centers in Germany, 2 in Italy), randomized, open-label trial; 4018 patients with ACS (41.1% suspected STEMI, 46.2% suspected NSTEMI, remainder unstable angina) who were having invasive evaluation were randomly assigned to ticagrelor (n=2012) or prasugrel (n=2006) strategies.
  • Funding: German Center for Cardiovascular Research; Deutsches Herzzentrum München.



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