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Ticagrelor vs Prasugrel for Acute Coronary Syndrome in Routine Care

2024; American Medical Association; Volume: 7; Issue: 12 Linguagem: Inglês

10.1001/jamanetworkopen.2024.48389

2574-3805

Nils Krüger, Johannes Krefting, Thorsten Kessler, Raphael Schmieder, Fabian Starnecker, Alexander Dutsch, Christian Graesser, Ulrike Meyer-Lindemann, T Storz, Irina Pugach, Christian Frieß, Zhifen Chen, Dario Bongiovanni, I. Manea, Tobias Dreischulte, Frank Offenborn, P Krase, Hendrik B. Sager, Jens Wiebe, Sebastian Kufner, Erion Xhepa, Michael Joner, Teresa Trenkwalder, Ulrich Gueldener, Adnan Kastrati, Salvatore Cassese, Heribert Schunkert, Moritz von Scheidt, Jonathan Adam, Reiner Anselm, Sara Ates, Sabine Bauer, Nicole Beck, J. Beckmann, Riccardo Berutti, Stefan Brandmaier, T.S. Bruun, Salvatore Cassese, Manuela Decker, Martin Dichgans, Philine Diesselhorst, H Domdey, S. Doppler, Martina Dreßen, Arne Dressler, Florent Dufour, Sven Duscha, Hans‐Henning Eckstein, Aiman Farzeen, Therese Feiler, Christian Frieß, I. Gall, Ulrich M. Gassner, Christian Gieger, Monica Gotor-Blazquez, Ulrich Gueldener, Nicolay Hammer, Johann S. Hawe, Verena Heidel, Thomas Hendel, Stefan Holdenrieder, Stephan Jonas, M. Kameric, Adnan Kastrati, Thorsten Kessler, Katharina Knoedlseder, Wolfgang Köenig, Florian Kohlmayer, Markus Krane, Dieter Kranzelmueller, Johannes Krefting, Nils Krüger, Anja Kroke, Harald Lahm, Rüediger Lange, Andreas Lehmann, Ling Li, Birgit Linkohr, Lars Mäegdefessel, Matthias Mann, Rainer Malik, Thomas Meitinger, Irina Neb, T O'Hehir, Shichao Pang, Benedikt Perl, Annette Peters, Fatemeh Peymani, R. Pichler, Heiko Pfister, Paola Pisano, Holger Prokisch, Irina Pugach, Lara Marie Reimer, Michaela Sander, Veronika Sanin, Lea D. Schlieben, Yannick Schlote, Sofie Schmid, Raphael Schmieder, Heribert Schunkert, Matthias Schwab, Megi Sharikadze, Ankit Sinha, Fabian Starnecker, Mirco Steger, Sophia Steigerwald, Ruoyu Sun, Moritz von Scheidt, Matias Wagner, Annie M. Westerlund, Jens Wiehler, Michael Wierer, Peter Zinterhof,

Venous Thromboembolism Diagnosis and Management

Importance In patients with acute coronary syndrome (ACS) undergoing invasive treatment, ticagrelor and prasugrel are guideline-recommended P2Y12 receptor inhibitors. The ISAR-REACT5 randomized clinical trial demonstrated superiority for prasugrel, although concerns were raised about the generalizability of some underpowered subgroup analyses. Objectives To emulate a randomized clinical trial evaluating the safety and effectiveness of ticagrelor vs prasugrel under the conditions of routine care in individuals with ACS planned to undergo an invasive treatment strategy. Design, Setting, and Participants This new-user cohort study included secondary data from a German statutory health insurance claims database between January 2012 and December 2021, using 1:1 propensity score nearest-neighbor matching to emulate ISAR-REACT5. Individuals with ACS receiving either ticagrelor or prasugrel treatment after hospital discharge were followed up for 1 year. Eligibility criteria closely emulated those of ISAR-REACT5 and included age of 18 years or older and cardiovascular risk factors. Data were analyzed from May 2023 to May 2024. Exposure Outpatient prescription of ticagrelor or prasugrel. Main Outcomes and Measures The primary end point was the composite of all-cause mortality, myocardial infarction (MI), or stroke within 1 year of outpatient treatment initiation. Secondary end points included individual components of the primary end point and stent thrombosis. The safety end point was major bleeding. A Cox proportional hazards regression model was fitted to the overall cohort. Results Of 17 642 propensity score–matched individuals (mean [SD] age, 63.1 [10.9] years; 73.9% male), 8821 received ticagrelor and 8821 received prasugrel. Agreement was met in 11 of 12 predefined agreement metrics when comparing the results with ISAR-REACT5. The primary composite end point of all-cause mortality, MI, or stroke occurred in 815 individuals (9.2%) receiving ticagrelor and 663 (7.5%) receiving prasugrel (hazard ratio [HR], 1.24; 95% CI, 1.12-1.37). Myocardial infarction (HR, 1.20; 95% CI, 1.06-1.36) and stroke (HR, 1.33; 95% CI, 1.02-1.74) each occurred significantly more often in the ticagrelor group. Analysis of all-cause mortality (HR, 1.27; 95% CI, 0.99-1.64), stent thrombosis (HR, 1.11; 95% CI, 0.89-1.30), and major bleeding (HR, 1.12; 95% CI, 0.96-1.32) revealed no significant differences between treatment groups. Subgroup analysis showed that prasugrel was associated with the primary composite end point in fewer individuals with ST-segment elevation MI (338 of 4941 [6.8%] vs 451 of 4852 [9.3%]). Conclusions and Relevance This cohort study found that prasugrel was associated with lower rates of all-cause mortality, MI, or stroke compared with ticagrelor in individuals with ACS undergoing an invasive treatment strategy in routine care, particularly in individuals with ST-segment elevation MI. The findings suggest that carefully designed database studies can complement and extend findings from randomized clinical trials, informing guidelines and clinical decision-making.