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November 2019

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Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. New England Journal of Medicine. DZHK authors: Stefanie Schüpke, Franz-Josef Neumann, Isabell Bernlochner, Christoph Liebetrau, Ibrahim Akin, Ulf Landmesser, Hugo A. Katus, Dirk Sibbing, Marion Janisch, Erion Xhepa, Sebastian Kufner, Christian W. Hamm, Heribert Schunkert, Karl-Ludwig Laugwitz & Adnan Kastrati

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After a heart attack or unstable angina pectoris, antiplatelet treatment with prasugrel is better for patients than with ticagrelor. This is the unexpected result of ISAR-REACT 5, an industry-independent study funded by the German Centre for Cardiovascular Research (DZHK) and the German Heart Centre Munich. After one year, fewer heart attacks, strokes and deaths occurred in the prasugrel-treated patient group than in the patient group receiving Ticagrelor. Also the risk for bleeding was not increased with Prasugrel.

The study included the entire spectrum of patients with ACS: 41 percent of the study participants were diagnosed with a heart attack with ST-segment elevation (STEMI), 46 percent with a heart attack without ST-segment elevation (NSTEMI) and 13 percent with unstable angina pectoris. NSTEMI differs from STEMI, among other things, in the absence of a specific elevation in one part of the ECG, the ST-segment. A cardiac catheter examination was planned for all patients.

The study participants were randomly assigned to a therapy with prasugrel or ticagrelor. Patients with Ticagrelor therapy received the drug even before the doctors examined their heart with the catheter. Prasugrel was only used to pre-treat patients with STEMI. Due to earlier study findings, patients with NSTEMI and unstable angina pectoris received prasugrel only after the heart anatomy was known.

In older patients (75 years and older) and patients weighing less than 60 kg, the maintenance dose of prasugrel was reduced from 10 to 5 mg per day. The majority of patients (84%) were treated with percutaneous coronary intervention, 2% received bypass surgery and 14% were treated conservatively.

After one year, the endpoint of death, recurrence of heart attack or stroke was less common in prasugrel-treated patients (6.9%) compared to patients receiving ticagrelor (9.3%). At the same time, the risk of bleeding was not increased with the prasugrel-based strategy.

The results of the study suggest that prasugrel is preferred in both STEMI and NSTEMI and in unstable angina pectoris.


DZHK Press release: Prasugrel proves superior in heart attacks