Objectives Prasugrel and ticagrelor both reduce ischaemic endpoints in high-risk acute coronary syndromes, compared with clopidogrel. However, comparative outcomes of these two newer drugs in the context of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains unclear. We sought to examine this question using the British Cardiovascular Interventional Society national database in patients undergoing primary PCI for STEMI.
Methods Data from January 2007 to December 2014 were used to compare use of P2Y12 antiplatelet drugs in primary PCI in >89 000 patients. Statistical modelling, involving propensity matching, multivariate logistic regression (MLR) and proportional hazards modelling, was used to study the association of different antiplatelet drug use with all-cause mortality.
Results In our main MLR analysis, prasugrel was associated with significantly lower mortality than clopidogrel at both 30 days (OR 0.87, 95% CI 0.78 to 0.97, P=0.014) and 1 year (OR 0.89, 95% CI 0.82 to 0.97, P=0.011) post PCI. Ticagrelor was not associated with any significant differences in mortality compared with clopidogrel at either 30 days (OR 1.07, 95% CI 0.95 to 1.21, P=0.237) or 1 year (OR 1.058, 95% CI 0.96 to 1.16, P=0.247). Finally, ticagrelor was associated with significantly higher mortality than prasugrel at both time points (30 days OR 1.22, 95% CI 1.03 to 1.44, P=0.020; 1 year OR 1.19 95% CI 1.04 to 1.35, P=0.01).
Conclusions In a cohort of over 89 000 patients undergoing primary PCI for STEMI in the UK, prasugrel is associated with a lower 30-day and 1-year mortality than clopidogrel and ticagrelor. Given that an adequately powered comparative randomised trial is unlikely to be performed, these data may have implications for routine care.
- antiplatelet drugs
- primary PCI
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IO and AS contributed equally.
Contributors MAM, IO and AS designed the study, acquired and interpreted data, and drafted the first draft of manuscript. IO analysed the data. MAM and IO agree to be the guarantors who are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. NC, TK, PL, JB, MR, DJRH-S, MAdB and AB made substantial contributions to the design of the work and critically revised the report.
Funding Unrestricted educational grant from Daiichi Sankyo to MAM.
Disclaimer The funder had no role in the design of study, preparation of manuscript or access to the contents of the manuscript prior to submission.
Competing interests MAM has received unrestricted educational grants from Terumo and Daiichi Sankyo. NC has received unrestricted research grants from Haemonetics, HeartFlow, Boston Scientific and speaker fees/consultancy from Haemonetics, HeartFlow, Boston Scientific, Abbott Vascular, Volcano-Phillips.
Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.
Provenance and peer review Not commissioned; externally peer reviewed.