Comparative Efficacy and Safety of Prasugrel, Ticagrelor, and Standard-Dose and High-Dose Clopidogrel in Patients Undergoing Percutaneous Coronary Intervention

Abstract

Authors aimed to compare efficacy and safety of prasugrel, ticagrelor, and standard-dose (SD) and high-dose (HD) clopidogrel in patients undergoing percutaneous coronary intervention (PCI). PubMed, EMBASE, CENTRAL, and clinicaltrials.gov were searched for studies comparing prasugrel, ticagrelor, SD and HD clopidogrel in patients undergoing PCI. Frequentist and Bayesian network meta-analyses were performed besides direct pairwise comparisons. Thirty trials, comprising 34,563 person-year data, were included. Prasugrel emerged as a best drug to prevent definite or probable stent thrombosis, followed by HD clopidogrel and ticagrelor, with SD clopidogrel being the worst. Myocardial infarction was least likely to be prevented by SD clopidogrel after PCI, and remaining 3 were superior to it with little difference among them. SD clopidogrel was least effective in preventing cardiovascular deaths after PCI. Prasugrel was most effective in preventing cardiovascular deaths, although having only small advantage over ticagrelor and HD clopidogrel. Ticagrelor reduced all-cause mortality by a small margin compared with rest of treatments. SD clopidogrel, followed by ticagrelor, resulted in significantly lower thrombolysis in myocardial infarction major bleeding complications compared with prasugrel. Analysis of any bleeding revealed similar trend. HD clopidogrel performed better than prasugrel in terms of bleeding complications. In conclusion, Prasugrel is likely most effective drug to prevent post-PCI ischemic events but at the expense of higher bleeding. Ticagrelor followed by HD clopidogrel seems to strike the right balance between efficacy and safety. HD clopidogrel can be considered as an alternative to newer P2Y12 inhibitors.

Comparative Effectiveness of Oral Antiplatelet Agents in Patients with Acute Coronary Syndrome

“…Further, in the absence of a proper head‐to‐head study, no clear guidance is available on the selection of ticagrelor versus prasugrel . Meta‐analyses attempting to compare the efficacy of prasugrel and ticagrelor indirectly produced conflicting conclusions, and an observational study suffered from methodological inadequacy in comparing clinical outcomes . In addition, a recent prospective trial comparing the efficacy of ticagrelor and prasugrel did not enroll an adequate number of participants and was terminated prematurely .…”

“…23,24 Meta-analyses attempting to compare the efficacy of prasugrel and ticagrelor indirectly produced conflicting conclusions, and an observational study suffered from methodological inadequacy in comparing clinical outcomes. [25][26][27] In addition, a recent prospective trial comparing the efficacy of ticagrelor and prasugrel did not enroll an adequate number of participants and was terminated prematurely. 28 To help fill this ongoing research gap and to provide further insight into the use of antiplatelet agents in the real world, we studied timeto-event estimates of the three antiplatelet medications from day 30 to day 365 following discharge from an ACS-PCI hospitalization using an insurance claims database.…”

Antiplatelet therapy before cardiac surgery

“…The antiproliferative properties of the eluted drugs were [23]. The need to increase the intensity and specificity, as well as to prolong the duration, of DAPT was the direct consequence and the right choice to protect patients from deleterious acute stent thrombosis [24]. There are still more aspects of midterm DAPT to be clarified for every specific stent subcategory, but the tendency seems, however, to be towards longer periods of DAPT therapy.…”

Safety and effectiveness of the new P2Y12r inhibitor agents vs clopidogrel in ACS patients according to the geographic area: East Asia vs Europe

“…1-year FU could be explained by a different risk profile of this population, for both thrombophilia and bleeding, compared to Europeans.bleeding complications for the new-molecules treated cohorts15,16 . In our population, ticagrelor doesn't increase bleeding in East Asian patients, despite of a reduction of incidence of death and myocardial infarction.…”