Head to head comparison of Prasugrel versus Ticagrelor in patients with acute coronary syndrome: a systematic review and meta-analysis of randomized trials.

Background: Prasugrel and Ticagrelor are emerging antiplatelet drugs that might have the potential to replace currently used antiplatelet agents. Previous analyses comparing prasugrel with ticagrelor mainly focused on an indirect comparison whereas direct comparison was reported only in a few recently published trials. We aimed to systematically carry out a head to head comparison of the adverse clinical outcomes which were associated with prasugrel versus ticagrelor in patients with acute coronary syndrome (ACS).

Methods: Studies comparing prasugrel with ticagrelor (head to head comparison) were searched from online databases. Adverse cardiovascular outcomes were considered as the primary endpoints whereas bleeding outcomes were considered as the secondary endpoints in this analysis. The latest version of the RevMan software was used to carry out subgroup analyses whereby odds ratios (OR) with 95% confidence intervals (CI) and the calculated probability (P) were generated.

Results: Four studies with a total number of 563 patients (2012 - 2016) were included (282 patients were treated with prasugrel and 281 patients were treated with ticagrelor). Results of this analysis did not show any significant difference in mortality between prasugrel and ticagrelor with OR: 1.52, 95% CI: 0.42 - 5.45; P = 0.52. In addition, myocardial infarction, major adverse cardiac events, stroke and stent thrombosis were also not significantly different with OR: 0.59, 95% CI: 0.08 - 4.58; P = 0.62, OR: 0.91, 95% CI: 0.37 - 2.21; P = 0.83, OR: 0.60, 95% CI: 0.08 - 4.58; P = 0.62 and OR: 0.59, 95% CI: 0.08 - 4.58; P = 0.62 respectively. Thrombolysis in myocardial infarction (TIMI) defined minor bleeding, and minimal bleeding were also not significantly different between these two newer antiplatelet agents with OR: 3.11, 95% CI: 0.48 - 19.94; P = 0.23, and OR: 2.39, 95% CI: 0.35 - 16.42; P = 0.38 respectively. Moreover, bleeding defined by the academic research consortium was also similarly manifested with OR: 0.92, 95% CI: 0.39 - 2.13; P = 0.84.

Conclusion: In patients with ACS, both prasugrel and ticagrelor showed similar adverse cardiovascular outcomes and bleeding events. No significant difference was observed between these two newer antiplatelet agents during this head to head comparison. However, upcoming trials with long term follow up periods might be expected to completely solve this important clinical issue.