Ticagrelor or Prasugrel in Patients With ST-Segment–Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND:Data on the comparative efficacy and safety of ticagrelor versus prasugrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) are limited. We assessed the efficacy and safety of ticagrelor versus prasugrel in a head-to-head comparison in STEMI patients undergoing primary PCI. METHODS:In this pre-specified subgroup analysis, we included 1653 patients with STEMI randomized to receive ticagrelor or prasugrel in the setting of the ISAR REACT-5 trial. The primary endpoint was the incidence of death, myocardial infarction or stroke at 1 year after randomization. The secondary endpoint was the incidence of bleeding defined as Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding at 1 year after randomization. RESULTS:The primary endpoint occurred in 83 patients (10.1%) in the ticagrelor group and in 64 patients (7.9%) in the prasugrel group (hazard ratio [HR]=1.31; 95% confidence interval [CI] 0.95-1.82; P=0.10). One-year incidence of all-cause death (4.9% vs. 4.7%; P=0.83), stroke (1.3% vs. 1.0%; P=0.46) and definite stent thrombosis (1.8% vs. 1.0%; P=0.15) did not differ significantly in patients assigned to ticagrelor or prasugrel. One-year incidence of myocardial infarction (5.3% vs. 2.8%; HR=1.95 [1.18-3.23], P=0.010) was higher with ticagrelor than with prasugrel. BARC type 3 to 5 bleeding occurred in 46 patients (6.1%) in the ticagrelor group and in 39 patients (5.1%) in the prasugrel group (HR=1.22 [0.80-1.87]; P=0.36). CONCLUSIONS:In patients with STEMI undergoing primary PCI, there was no significant difference in the primary endpoint between prasugrel and ticagrelor. Ticagrelor was associated with a significant increase in the risk for recurrent myocardial infarction. CLINICAL TRIAL REGISTRATION:URLhttps://www.clinicaltrials.gov; Unique identifier NCT01944800