What is the preferred antiplatelet therapy, ticagrelor (ticagrelor) or prasugrel (prasugrel), in patients with acute coronary syndrome (ACS)?

Ticagrelor vs Prasugrel in Acute Coronary Syndrome

Ticagrelor is the preferred antiplatelet therapy over prasugrel for most patients with acute coronary syndrome (ACS) due to its broader efficacy across all ACS populations and more favorable mortality benefit. 1

Comparison of Efficacy and Safety

Ticagrelor

• Recommended for patients with ACS (NSTE-ACS or STEMI) treated with:
  • DAPT after coronary stent implantation
  • Medical therapy alone without revascularization 1
• Provides fewer ischemic complications and stent thromboses compared to clopidogrel 1
• Associated with reduced all-cause mortality in the PLATO trial 2
• Can be used in broader patient populations, including medically managed ACS 1
• Reversible P2Y12 inhibitor with faster onset and offset of action (3-5 days) 3

Prasugrel

• Reasonable option for patients with ACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation who:
  • Are not at high risk for bleeding complications
  • Do not have a history of stroke or TIA 1
• Not recommended for:
  • Patients with prior history of stroke or TIA (Class III: Harm) 1
  • Patients ≥75 years of age (no net benefit)
  • Patients <60 kg (no net benefit)
  • Medically managed ACS patients (Class III recommendation) 1
• Irreversible P2Y12 inhibitor with longer recovery time (7 days) 3

Decision Algorithm

1. First, assess patient characteristics:

   • History of stroke/TIA? → Choose ticagrelor (prasugrel contraindicated)
   • Age ≥75 years? → Choose ticagrelor (prasugrel shows no net benefit)
   • Weight <60 kg? → Choose ticagrelor (prasugrel shows no net benefit)
   • Medically managed ACS? → Choose ticagrelor (prasugrel not recommended)

2. Second, assess bleeding risk:

   • High bleeding risk? → Prefer ticagrelor
   • Low bleeding risk with planned PCI? → Either agent appropriate

3. Third, consider compliance factors:

   • Ticagrelor requires twice-daily dosing (90 mg BID)
   • Prasugrel requires once-daily dosing (10 mg daily)
   • Poor medication adherence may favor prasugrel's once-daily regimen

Important Clinical Considerations

• Dyspnea occurs in up to 15% of patients on ticagrelor but is rarely severe enough to cause discontinuation 1
• Both agents have increased bleeding risk compared to clopidogrel 1, 4
• Prasugrel should be discontinued at least 7 days before surgery, while ticagrelor requires 3-5 days 3
• Ticagrelor's efficacy may be reduced with aspirin doses >100 mg daily 3
• Real-world data suggests ticagrelor may be more effective in reducing ischemic events during the first year after ACS, despite increased risk of major bleeding 4

Special Situations

• Switching from clopidogrel: In patients with ACS previously exposed to clopidogrel, switching to ticagrelor is recommended early after hospital admission at a loading dose of 180 mg 1
• Perioperative management: Continue aspirin perioperatively if bleeding risk allows, and resume the recommended antiplatelet therapy as soon as possible post-operatively 1
• Proton pump inhibitors: Recommended with DAPT to reduce gastrointestinal bleeding risk 1

While both ticagrelor and prasugrel are more effective than clopidogrel in reducing ischemic events in ACS patients, ticagrelor has broader indications and fewer contraindications, making it the preferred option for most patients with ACS.