Presentation (CTI)

OBJECTIVES: Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor is the standard treatment for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Although both ticagrelor and prasugrel are recommended by guidelines, real-world comparative evidence remains limited. This study aimed to compare the effectiveness and safety of prasugrel versus ticagrelor among ACS patients following PCI using a large, multicenter database.
METHODS: This study used a retrospective cohort design, with data sourced from the TriNetX global collaborative Network (2010-2024). Adult patients with ACS who initiated prasugrel or ticagrelor within 24 hours post-PCI were included. The efficacy endpoint was a 1-year all-cause mortality. The safety endpoints included major bleeding events and repeat revascularization. Propensity score matching was applied to balance baseline characteristics. Subgroup and sensitivity analyses were performed to assess robustness and consistency of the findings.
RESULTS: Of 78,032 eligible patients, 20,009 matched pairs were selected. Prasugrel use was associated with a significantly lower risk of all-cause mortality (HR 0.66; 95% CI 0.612-0.712). There was no significant difference in the incidence of major bleeding between the two groups (HR 0.917; 95% CI 0.825-1.021). However, prasugrel was associated with a higher risk of repeat revascularization (HR 1.387; 95% CI 1.301-1.479). Treatment effects were consistent across clinical subgroups and sensitivity analyses.
CONCLUSIONS: In this large real-world cohort study of ACS patients undergoing PCI, prasugrel was associated with reduced risks of mortality compared with ticagrelor, without an increase in major bleeding. The higher rate of repeat revascularization in prasugrel users warrants further investigation. These results may help guide clinical decision-making and value-based assessments regarding optimal P2Y12 inhibitor selection in the treatment of ACS.