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A Class 1 indication for patients with acute coronary syndrome (ACS) is dual antiplatelet inhibitors therapy (DAPT) including aspirin and a P2Y12 inhibitor. Randomized controlled trials (RCTs) have shown prasugrel and ticagrelor are superior to clopidogrel, but no RCT has directly compared these three currently approved oral P2Y12 inhibitors for safety and efficacy.
Relevant RCTs were included in a Bayesian network meta-analysis using mixed treatment comparison models to compare efficacy and safety.
We included data from 8 RCTs involving 105,487 patients. Both ticagrelor and prasugrel decreased MACE and recurrent MI rates compared with clopidogrel, and there was no difference between the two. In addition, both decreased the stent thrombosis rate compared with clopidogrel, prasugrel being the more effective of the two.Ticagrelor use was also associated with improved all-cause mortality compared with clopidogrel; no difference was found between prasugrel and clopidogrel. Prasugrel use was associated with significantly increased risk for major bleeding compared with clopidogrel, but compared with ticagrelor, only a non-significant trend toward increased risk was seen. In treatment ranking, ticagrelor was the most efficacious, and prasugrel was the least safe.
For patient with ACS, ticagrelor has the best net efficacy and safety profile among the currently approved oral P2Y12 inhibitors.
CORONARY: Acute Coronary Syndromes