Prasugrel and ticagrelor are similarly effective during the first year after MI. Economically motivated early post-discharge switches to clopidogrel were not associated with an increased risk of ischemic events. (Comparison of Prasugrel and Ticagrelor in the Treatment of Acute Myocardial Infarction [PRAGUE-18]; NCT02808767).

BACKGROUND:No randomized head-to-head comparison of the efficacy and safety of ticagrelor and prasugrel has been published in the 7 years since the higher efficacy of these newer P2Y 12 inhibitors were first demonstrated relative to clopidogrel. METHODS:This academic study was designed to compare the efficacy and safety of prasugrel and ticagrelor in acute myocardial infarction treated with primary or immediate percutaneous coronary intervention. A total of 1230 patients were randomly assigned across 14 sites to either prasugrel or ticagrelor, which was initiated before percutaneous coronary intervention. Nearly 4% were in cardiogenic shock, and 5.2% were on mechanical ventilation. The primary end point was defined as death, reinfarction, urgent target vessel revascularization, stroke, or serious bleeding requiring transfusion or prolonging hospitalization at 7 days (to reflect primarily the in-hospital phase). This analysis presents data from the first 30 days (key secondary end point). The total followup will be 1 year for all patients and will be completed in 2017. RESULTS:The study was prematurely terminated for futility. The occurrence of the primary end point did not differ between groups receiving prasugrel and ticagrelor (4.0% and 4.1%, respectively; odds ratio, 0.98; 95% confidence interval, 0. 55-1.73; P=0.939). No significant difference was found in any of the components of the primary end point. The occurrence of key secondary end point within 30 days, composed of cardiovascular death, nonfatal myocardial infarction, or stroke, did not show any significant difference between prasugrel and ticagrelor (2.7% and 2.5%, respectively; odds ratio, 1.06; 95% confidence interval, 0.53-2.15; P=0.864). CONCLUSIONS:This head-to-head comparison of prasugrel and ticagrelor does not support the hypothesis that one is more effective or safer than the other in preventing ischemic and bleeding events in the acute phase of myocardial infarction treated with a primary percutaneous coronary intervention strategy. The observed rates of major outcomes were similar but with broad confidence intervals around the estimates. These interesting observations need to be confirmed in a larger trial. 1604 F low restoration through an infarct-related artery via implantation of intracoronary stents during primary percutaneous coronary intervention (PCI) is, if possible, the preferred reperfusion therapy in patients with acute myocardial infarction (AMI) with ST-segment elevation (STEMI). CLINICAL TRIAL REGISTRATION:1 The highest thrombotic risk associated with this condition requires intensive antithrombotic treatment.2 In addition to aspirin, guidelines recommend the use of ticagrelor or prasugrel over clopidogrel. 1,3 Except for patients after an ischemic stroke, in whom prasugrel is contraindicated, class and level of guideline recommendations are identical for both agents. Physicians are increasingly being confronted with the need to select a P2Y 12 antagonist as part of the daily care of patients with AMI. For all practical pu...