Home > Acute coronary syndrome, Journal Club > Journal Club 29 August 2012

Journal Club 29 August 2012


Prasugrel versus Clopidogrel for Acute Coronary Syndromes without Revascularization





The effect of intensified platelet inhibition for patients with unstable angina or myocardial
infarction without ST-segment elevation who do not undergo revascularization
has not been delineated.


In this double-blind, randomized trial, in a primary analysis involving 7243 patients
under the age of 75 years receiving aspirin, we evaluated up to 30 months of treatment
with prasugrel (10 mg daily) versus clopidogrel (75 mg daily). In a secondary analysis
involving 2083 patients 75 years of age or older, we evaluated 5 mg of prasugrel versus
75 mg of clopidogrel.


At a median follow-up of 17 months, the primary end point of death from cardiovascular
causes, myocardial infarction, or stroke among patients under the age of
75 years occurred in 13.9% of the prasugrel group and 16.0% of the clopidogrel
group (hazard ratio in the prasugrel group, 0.91; 95% confidence interval [CI], 0.79
to 1.05; P = 0.21). Similar results were observed in the overall population. The prespecified
analysis of multiple recurrent ischemic events (all components of the primary
end point) suggested a lower risk for prasugrel among patients under the age of
75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P = 0.04). Rates of severe and intracranial
bleeding were similar in the two groups in all age groups. There was no significant
between-group difference in the frequency of nonhemorrhagic serious adverse
events, except for a higher frequency of heart failure in the clopidogrel group.


Among patients with unstable angina or myocardial infarction without ST-segment elevation,
prasugrel did not significantly reduce the frequency of the primary end point,
as compared with clopidogrel, and similar risks of bleeding were observed.
Will be published in due course


  • Medically managed ACS is a heterogeneous group. The patients enrolled in this trial did have high prevalence of prior coronary heart disease (infarction or revascularisation) and diabetes mellitus (approximately 40%)
  • The trial was negative for the primary end-point.
  • The diverging curves at 12 months (qualitative and landmark analysis) and forest plot observations with respect to smokers and younger patients are hypothesis generating.
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