One-Year Outcomes From PRAGUE-18 Trial Compare Prasugrel and Ticagrelor
January 22, 2018—One-year outcomes from the PRAGUE-18 trial, a comparison of prasugrel and ticagrelor for the treatment of acute myocardial infarction (MI), were published by Zuzana Motovska, MD, et al in Journal of the American College of Cardiology (JACC; 2018;71:371–381).
According to the investigators, the early outcomes of patients in the PRAGUE-18 study demonstrated no significant differences between these two potent P2Y12 inhibitors. The 1-year follow-up of PRAGUE-18 focused on a comparison of safety and efficacy between prasugrel and ticagrelor and the risk of major ischemic events related to an economically motivated postdischarge switch to clopidogrel.
As summarized in JACC, a total of 1,230 patients with acute MI treated with primary percutaneous coronary intervention were randomized to prasugrel or ticagrelor with an intended treatment duration of 12 months. The combined endpoint was cardiovascular death, MI, or stroke at 1 year. Because patients had to cover the costs of study medication after hospital discharge, some patients decided to switch to clopidogrel.
The investigators reported that the endpoint occurred in 6.6% of prasugrel patients and in 5.7% of ticagrelor patients (hazard ratio, 1.167; 95% confidence interval, 0.742–1.835; P = .503).
No significant differences were found in cardiovascular death (3.3% vs 3%; P = .769), MI (3% vs 2.5%; P = .611), stroke (1.1% vs 0.7%; P = .423), all-cause death (4.7% vs 4.2%; P = .654), definite stent thrombosis (1.1% vs 1.5%; P = .535), all bleeding (10.9% vs 11.1%; P = .999), and thrombolysis-in-MI major bleeding (0.9% vs 0.7%; P = .754).
The percentage of patients who switched to clopidogrel for economic reasons was 34.1% (n = 216) for prasugrel and 44.4% (n = 265) for ticagrelor (P = .003). Compared with patients who continued the study medications, patients who were economically motivated to switch to clopidogrel had a lower risk of major cardiovascular events; however, they also had a lower ischemic risk.
The investigators concluded that prasugrel and ticagrelor are similarly effective during the first year after MI and that economically motivated early postdischarge switches to clopidogrel were not associated with an increased risk of ischemic events.