Prasugrel vs. Ticagrelor: Sweden’s Real-World Stalemate

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Key Takeaway

In a Swedish trial of 17,095 patients who received stents for an acute coronary syndrome, making prasugrel the default blood thinner instead of ticagrelor did not significantly lower the 1-year rate of death, heart attack or stroke. Prasugrel showed a small edge on major bleeding. The large advantage reported by an earlier trial did not appear in routine practice.

Two Pills, One Cath Lab, and a Guideline Under Pressure

Picture a 71-year-old retired ferry mechanic lying on a catheterization table at 3 a.m. A clot has narrowed one of his coronary arteries, and a stent has just propped it open. Before he leaves the hospital, someone has to choose his next year of medication. Alongside aspirin, he will take one of 2 powerful antiplatelet drugs: prasugrel or ticagrelor.

For most of the last decade, that choice in Europe leaned toward prasugrel. In 2019 the ISAR-REACT 5 trial randomly assigned 4,018 patients to one drug or the other. Death, heart attack or stroke at 1 year occurred in 9.3% of patients on ticagrelor and 6.9% on prasugrel^[2]. European guidelines moved prasugrel ahead.

Skeptics were not convinced. It was one open-label trial, and critics questioned whether…