a-t 2016; 47: 86

PRAGUE-18 - is prasugrel (EFIENT) as effective as ticagrelor (BRILIQUE)? We see certain advantages for ticagrelor (BRILIQUE) versus clopidogrel (PLAVIX, generics) in dual platelet inhibition following an acute coronary syndrome, but not for prasugrel (EFIENT; a-t 2011; 42: 1-3 and 2009; 40: 34-36). The publicly financed PRAGUE-18 study (1) has now been presented at the European Society of Cardiology Congress and published at the same time. In this study, prasugrel was compared directly to ticagrelor in patients receiving percutaneous coronary intervention due to an acute infarction with ST segment elevation. 1,230 patients with symptoms of less than 120 minutes duration were randomised immediately after hospital admission, and received either prasugrel (loading dose of 60 mg followed by 10 mg daily thereafter) or ticagrelor (loading dose of 180 mg followed by 2 x 90 mg daily) in addition to their other treatment, including 100 mg acetylsalicylic acid (ASA; ASPIRIN, generics) daily. Coronary intervention was performed in 95% of cases, was mostly primary (99%) and involved stent implantation (96%). The primary endpoint was a combination of death, re-infarction, stroke, severe bleeding, prolonged hospital stay or urgent revascularisation of the target vessel within seven days. The study was designed to show superiority of ticagrelor. No difference was apparent (4.0% versus 4.1%; odds ratio 0.98 with 95% confidence interval 0.55-1.73; p = 0.94). Similarly, no differences were observed for the individual components of the primary endpoint or a combination endpoint comprising myocardial infarction, stroke or cardiovascular death within 30 days. The authors suggest that both drugs are equivalent (1). However, this implication is not readily accepted, and certainly not in a completely underpowered study: During the discussion held at the congress, it became clear that more than 14,000 patients would have been required for an adequately powered superiority trial (2). In our opinion, the study results are not conclusive. We still consider ticagrelor to be the medication of choice for temporary dual platelet inhibition in conjunction with ASA following acute coronary syndrome, -Ed.