(P-164) Comparative Effectiveness and Safety of Prasugrel versus Ticagrelor in Patients with Acute Coronary Syndrome Undergoing Percutaneous Transluminal Coronary Angioplasty

Background: There is not enough evidence on which among prasugrel and ticagrelor is superior in terms of effectiveness and safety for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary angioplasty (PTCA), especially in Indian population.

Objectives: To compare the effectiveness and safety of prasugrel versus ticagrelor in patients with ACS in the 6 months following PTCA. The null hypothesis set a priori was that there is no difference in effectiveness or safety between these two medications.

Methods: This was a prospective cohort study. Adult patients with ACS who underwent PTCA at our hospital and took ticagrelor or prasugrel were enrolled with follow-ups at 1, 3, and 6 months post-PTCA . The primary outcomes were 3-point major adverse cardiovascular events (3P-MACE ) (cardiovascular death, myocardial infarction [MI] and stroke), bleeding (all types as per the Bleeding Academic Research Consortium) and dyspnoea. The secondary outcomes were individual 3P-MACE components, stent thrombosis and non-cardiovascular death. Propensity score matching-based comparisons were carried out (matched for age, gender, comorbidity, medications and ACS type). Hazard ratios were calculated using Kaplan-Meier survival analysis after propensity score matching.

Results: 71 patients were included in each of the two cohorts. The prasugrel cohort had a mean (SD) age of 57.07 (9.02) years with 9.86% female while the ticagrelor cohort had a mean age of 58.89 (9.27) years with 11.27% female. The use of ticagrelor was associated with an increased risk of a 3P-MACE events when compared to prasugrel (absolute difference, -2.80%, 95% CI, -11.2%-5.59%; adjusted HR, 0.59; 95% CI, 0.17-2.06). Bleed was more common among participants using ticagrelor (absolute difference, -4.20%, 95% CI, -12.99%-4.54%; adjusted HR, 0.49; 95% CI, 0.15-1.62), as was dyspnoea (absolute difference, -5.60%, 95% CI, -15.40%-4.13%; adjusted HR, 0.40, 95% CI, 0.13-1.18). Ticagrelor use was associated with an increased risk of cardiovascular death (absolute difference, -4.20%, 95% CI, -10.25%-1.80%; adjusted HR, 0.23, 95% CI, 0.04-1.32), and slightly increased risks of MI (absolute difference, 0%, 95% CI, -6.62% to 6.62%; adjusted HR, 0.89, 95% CI, 0.18 to 4.42) and stent thrombosis (absolute difference, 0%, 95% CI, -3.88%-3.88%; adjusted HR, 0.96, 95% CI, 0.06 to 15.4). There was no incidence of non-cardiovascular death or stroke in either cohort.

Conclusions: In patients with ACS undergoing PTCA, prasugrel has a favorable profile over ticagrelor in terms of lowering incidence of 3P-MACE, bleeding and dyspnoea in the 6-month period post-PTCA in Indian population. However, the small sample size and the low power of the study limit us from drawing any definitive conclusions.