No abstract

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: URL: https://www.clinicaltrials.gov; Unique identifier NCT01944800

Progression of atherosclerotic plaque in coronary arteries is characterized by complex cellular and non-cellular molecular interactions. Within recent years, atherosclerosis has been recognized as inflammation-driven disease condition, where progressive stages are characterized by morphological changes in plaque composition but also relevant molecular processes resulting in increased plaque vulnerability. While existing intravascular imaging modalities are able to resolve key morphological features during plaque progression, they lack capability to characterize the molecular profile of advanced atherosclerotic plaque. Because hybrid imaging modalities may provide incremental information related to plaque biology, they are expected to provide synergistic effects in detecting high risk patients and lesions. The aim of this article is to review existing literature on intravascular molecular imaging approaches, and to provide clinically oriented proposals of their application. In addition, we assembled an overview of future developments in this field geared towards detection of patients at risk for cardiovascular events.