Methodology Score: 4/5
Usefulness Score: 4/5

Schüpke S, et al N Engl J Med. 2019 Oct 17;381(16):1524-1534.

Editorial: Ticagrelor or Prasugrel in Acute Coronary Syndromes – The Winner Takes It All?

Question and Methods: This open-label multicenter trial was the first head-to-head trial examining Ticagrelor vs Prasugrel as part of DAPT in ACS requiring angiography.

Findings: The authors found that patients taking Prasugrel had lower risk of MI, CVA, and death at one year in comparison to Ticagrelor (9.3% vs 6.9%, HR 1.36, 95% CI 1.09 – 1.70, P = 0.006).  There were no differences in bleeding between the drugs.

Limitations: The main limitation of this trial is the open-label nature of the design.

Interpretation: This paper gives evidence that DAPT with ASA and Prasugrel is superior to DAPT with ASA and Ticagrelor.  Due to the differences in effect size with STEMI vs NSTEMI and between timing of drugs, more studies are needed to delineate the best treatment strategy.

By: Dr. Scott Odorizzi

Hans Rosenberg
Dr. Rosenberg is an emergency physician at the Ottawa Hospital, assistant professor at the University of Ottawa, and Director of the Digital Scholarship and Knowledge Dissemination Program.