June 19, 2026Journal of the American College of Cardiology
Ticagrelor or Prasugrel in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes
Why the study?
Does ticagrelor compared to prasugrel improve clinical outcomes in patients with NSTE-ACS undergoing planned invasive management?
Population
2,365 patients with non-ST-segment elevation acute coronary syndromes and planned invasive management
Comparison
Ticagrelor started immediately after randomization vs Prasugrel started after coronary angiography
Design
RCT, Randomized (subgroup of the ISAR-REACT 5 trial)
Follow-up
1 year
Key result
Ticagrelor resulted in a higher 1-year risk of death, MI, or stroke compared to prasugrel in patients with NSTE-ACS (8.7% vs 6.3%; HR 1.41, 95% CI 1.04-1.90).
Authors
Discussion
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Member takes
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources linked on every quote.
“A shift from ticagrelor to prasugrel occurred in Denmark following the findings of the ISAR-REACT 5 trial and the updated ESC guideline recommendation favoring prasugrel. In 2019, more than 99% of patients received ticagrelor; by 2022, 89% received prasugrel.”
Overview
Ticagrelor associated with higher ischemic events than prasugrel; leaves open whether this reflects confounding or a true difference.
Key Points
- This study aims to compare the benefits and risks of ticagrelor to prasugrel in patients with NSTE-ACS undergoing invasive management.
- Post hoc analysis of ISAR-REACT 5 trial subgroups (UA and NSTEMI)
- Included 1,179 patients assigned to ticagrelor and 1,186 to prasugrel
- Primary endpoint was a composite of death, MI, or stroke during 1-year follow-up.
- Primary endpoint reached in 101 (8.7%) patients on ticagrelor vs. 73 (6.3%) on prasugrel (HR: 1.41; 95% CI: 1.04 to 1.90)
- All-cause death HR for ticagrelor was 1.43 (95% CI: 0.93 to 2.21) and MI HR was 1.43 (95% CI: 0.94 to 2.19)
- Safety endpoint occurred in 49 (5.2%) patients on ticagrelor vs. 41 (4.7%) on prasugrel (HR: 1.09; 95% CI: 0.72 to 1.65)
Study Design
Type
RCT (n=2,365)
Structured PICO
Does ticagrelor compared to prasugrel improve clinical outcomes in patients with NSTE-ACS undergoing planned invasive management?
P
Population
2,365 patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and planned invasive management, followed for 1 year.
I
Intervention
Ticagrelor started immediately after randomization
C
Comparator
Prasugrel started after coronary angiography
O
Outcome
Composite of death, MI, or stroke during 1-year follow-upcomposite
Main Result
Hazard Ratio: 1.41 (95% CI 1.04–1.9)
Absolute Event Rate: 8.7% vs 6.3%
In patients with NSTE-ACS planned for invasive management, prasugrel was superior to ticagrelor in reducing the 1-year risk of death, MI, or stroke without increasing major bleeding.
Limitations
- Post hoc nature of the analysis
Cite This Study
Valina et al. (2020) conducted an RCT in Non-ST-segment elevation acute coronary syndromes (NSTE-ACS) (n=2,365). Ticagrelor vs. Prasugrel was evaluated on Composite of death, MI, or stroke (HR 1.41, 95% CI 1.04 to 1.90). Ticagrelor resulted in a higher 1-year risk of death, MI, or stroke compared to prasugrel in patients with NSTE-ACS (8.7% vs 6.3%; HR 1.41, 95% CI 1.04-1.90).