Coronary Artery Disease
Comparison of Ticagrelor Versus Prasugrel to Prevent Periprocedural Myonecrosis in Acute Coronary Syndromes

https://doi.org/10.1016/j.amjcard.2015.04.050Get rights and content

Guidelines recommend a ticagrelor loading dose (LD) before PCI or a prasugrel LD at the time of percutaneous coronary intervention (PCI) in intermediate and high-risk non–ST-elevation acute coronary syndrome (NSTE-ACS). However, achieving an optimal PR inhibition at the time of PCI is critical to prevent adverse events and depends on the timing of LD intake in relation to PCI. We aimed to compare the rate of myonecrosis related to PCI in patients with NSTE-ACS receiving ticagrelor pretreatment versus prasugrel at the time of intervention. We prospectively randomized 213 patients with NSTE-ACS to a 180 mg of ticagrelor LD given as soon as possible after admission and before PCI or to a 60 mg LD of prasugrel given at the time of PCI. The primary end point was the rate of periprocedural myonecrosis as defined by an increase of >5 times the ninety-ninth percentiles in troponin-negative patients or a 20% increase in troponin-positive patients. The 2 groups were similar regarding baseline characteristics including clinical setting (p = 0.2). Procedural characteristics were also identical including the number of treated vessels and stenting procedures. Patients in the prasugrel group more often required emergent PCI (p = 0.001). Patients in the ticagrelor group had less periprocedural myonecrosis compared with those in the prasugrel group (19.8% vs 38.3%; p = 0.03). The rate of major adverse cardiovascular events and Bleeding Academic Research Consortium ≥2 at 1-month follow-up was low and similar between the 2 groups. In conclusion, a ticagrelor LD as soon as possible before PCI is superior to prasugrel at the time of PCI to prevent periprocedural myonecrosis in NSTE-ACS.

Section snippets

Methods

A prospective, monocenter, open-label randomized study was performed from January 2014 to September 2014. Patients between 18 and 75 years old who underwent PCI for an intermediate or high-risk NSTE-ACS and agreeing to participate in the study were eligible. The present study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution's human research committee. All patients gave an informed consent.

They were randomized

Results

The present study included 213 patients: 106 in the ticagrelor group and 107 in the prasugrel group. The 2 groups were similar in terms of baseline characteristics as summarized in Table 1. In particular, the rate of non–ST-elevation myocardial infarction as defined by a preprocedural troponin Ic more than the ninety-ninth percentiles was similar between the 2 groups (ticagrelor vs prasugrel: 53.8% vs 45.8%; p = 0.2).

The main angiographic and interventional characteristics are depicted in

Discussion

The present study demonstrated that pretreatment with a ticagrelor LD before PCI significantly reduced the occurrence of periprocedural myonecrosis in patients with NSTE-ACS who underwent PCI compared with prasugrel given at the time of PCI. Because periprocedural myonecrosis have been associated with short- and long-term clinical outcome, the present pilot study supports pretreatment with ticagrelor in intermediate and high-risk NSTE-ACS to improve the outcome.

Platelet-rich thrombus plays a

Disclosures

The present study was supported by a grant from the Assistance Publique—Hopitaux de Marseille (grant number 251929). Dr. Bonello received lecture fees from Sanofi (Paris, France), Eli Lilly (Indianapolis), and AstraZeneca (Londres) and Medicine Company (Parsippany) and research grant from Astrazeneca; Dr. Laine received lectures fee from Astrazeneca; and Dr. Paganelli received lecture fees from Sanofi, Eli Lilly, and AstraZeneca and research grant from Astrazeneca. None of the authors have

References (21)

There are more references available in the full text version of this article.

Cited by (30)

  • Prasugrel vs Ticagrelor for DAPT in Patients with ACS Undergoing PCI: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

    2020, Cardiovascular Revascularization Medicine
    Citation Excerpt :

    The cumulative Z-curve did not exceed the traditional boundary for statistical significance; thus, the result is inconclusive (Supplemental Figs. 4). In our meta-analysis of available trials [12–17] (6 RCTs, 6807 participants) comparing prasugrel and ticagrelor, there was no significant difference in MACE, cardiovascular mortality, all-cause mortality, MI, stent thrombosis, major bleeding, and all bleeding. A very large study would be required to reach a conclusive result.

  • Ticagrelor or Prasugrel in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

    2020, Journal of the American College of Cardiology
    Citation Excerpt :

    In the ACCOAST (Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention or as Pre-treatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction) trial that comprised patients with NSTE-ACS, pre-treatment with prasugrel before coronary anatomy was known did not reduce the risk of ischemic events compared with treatment in the catheterization laboratory, but increased the risk of bleeding substantially (10). A randomized study in 213 patients with NSTE-ACS comparing loading with ticagrelor as soon as possible after admission with prasugrel given at the time of PCI suggested a possible protection against peri-procedural myonecrosis by ticagrelor pre-treatment (19). In the ATLANTIC (Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST-Elevation Myocardial Infarction to Open the Coronary Artery) trial, pre-treatment with ticagrelor did not improve resolution of ST-segment elevation before PCI or Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 in the infarct-related artery (20).

  • Ticagrelor for stroke prevention in patients with vascular risk factors: A systematic review and meta-analysis

    2018, Journal of the Neurological Sciences
    Citation Excerpt :

    Five RCTs were conducted in China, one each in Japan, France and Czech Republic, whereas remaining were multinational trials. The control group consisted of clopidogrel in 8 RCTs [1,3,15,16,18–22], prasugrel in 2 RCTs [17,23], aspirin in one RCT [4], and placebo in one RCT [2]. The individual and pooled assessments of the risk of bias across included studies are presented in Supplemental Fig. II.

  • Comparison of prasugrel and ticagrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A meta-analysis of randomized and non-randomized studies

    2017, International Journal of Cardiology
    Citation Excerpt :

    Finally, we had a total of 9 publications for qualitative and quantitative analysis. Four studies were randomized trials [17,19,24,25] and five were observational [16,18,26–28]. The individual study characteristics, patient characteristics and inclusion/exclusion criteria of the included studies are shown respectively in Table 1, Table 2, and E-Table 3.

View all citing articles on Scopus

See page 342 for disclosure information.

View full text