The first ever head-to-head comparison between the P2Y12 receptor antagonists tricagrelor and prasugrel found no differences in safety or efficacy in patients in AMI and STEMI. The study, PRAGUE-18, was presented yesterday in a Hot Line session.
‘These results offer more freedom to clinicians to select an antiplatelet agent on top of aspirin for STEMI patients who receive dual antiplatelet therapy,’ said study presenter Petr Widimsky from the Cardiocenter of Charles University, Prague. ‘Based on previous results we had expected that during the first seven days prasugrel might be more effective, and that later ticagrelor might be superior. But we found that both drugs are very effective and safe, and significantly contribute to the excellent outcomes we now have in patients with AMI.’
Indeed, the trial was stopped early after interim analysis found no difference in endpoint results.
While aspirin is considered the cornerstone of treatment in ACS, there has been debate over whether it should be combined with ticagrelor or prasugrel. ESC guidelines have given both prasugrel and ticagrelor Ib recommendations in patients having primary PCI.
PRAGUE-18 study randomsied 1230 STEMI patients to prasugrel 60 mg followed by 10 mg/day for one year (5 mg/day if >75 years or <60 kg) or ticagrelor (180 mg orally followed by 90 mg b.i.d. for one year) prior to PCI.
The primary endpoint (defined as death, re-infarction, urgent target vessel revascularisation, stroke, serious bleeding requiring transmission or prolonged hospitalisation at seven days) was achieved in 4.0% of patients in the prasugrel group and 4.1% in the ticagrelor group. Additionally, no endpoint difference between the two groups was found at 30 days.
Widimsky explained that further analysis will be undertaken next year to explore the safety of any ‘economically motivated’ switch from prasugrel or ticagrelor to clopidogrel. ‘Notably in the Czech Republic these drugs are free to patients during their hospital stays, but following discharge they have to cover the costs of tricagrelor or prasugrel themselves. So some patients decide to switch to clopidogrel, which is fully covered by local health care,’ said Widimsky.
ESC Spokesman Andreas Baumbach from the University of Bristol, UK, applauded the trial and its motivation. ‘I think it is worth commenting,’ he said, ‘that we never thought we would see this study performed, and we should be grateful to the PRAGUE investigators for doing it.’
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