BACKGROUND: No randomized head-to-head comparison of the efficacy and safety of ticagrelor and prasugrel has been published in the 7 years since the higher efficacy of these newer P2Y12 inhibitors were first demonstrated relative to clopidogrel. METHODS: This academic study was designed to compare the efficacy and safety of prasugrel and ticagrelor in acute myocardial infarction treated with primary or immediate percutaneous coronary intervention. A total of 1230 patients were randomly assigned across 14 sites to either prasugrel or ticagrelor, which was initiated before percutaneous coronary intervention. Nearly 4% were in cardiogenic shock, and 5.2% were on mechanical ventilation. The primary end point was defined as death, reinfarction, urgent target vessel revascularization, stroke, or serious bleeding requiring transfusion or prolonging hospitalization at 7 days (to reflect primarily the in-hospital phase). This analysis presents data from the first 30 days (key secondary end point). The total follow-up will be 1 year for all patients and will be completed in 2017. RESULTS: The study was prematurely terminated for futility. The occurrence of the primary end point did not differ between groups receiving prasugrel and ticagrelor (4.0% and 4.1%, respectively; odds ratio, 0.98; 95% confidence interval, 0.55-1.73; P=0.939). No significant difference was found in any of the components of the primary end point. The occurrence of key secondary end point within 30 days, composed of cardiovascular death, nonfatal myocardial infarction, or stroke, did not show any significant difference between prasugrel and ticagrelor (2.7% and 2.5%, respectively; odds ratio, 1.06; 95% confidence interval, 0.53-2.15; P=0.864). CONCLUSIONS: This head-to-head comparison of prasugrel and ticagrelor does not support the hypothesis that one is more effective or safer than the other in preventing ischemic and bleeding events in the acute phase of myocardial infarction treated with a primary percutaneous coronary intervention strategy. The observed rates of major outcomes were similar but with broad confidence intervals around the estimates. These interesting observations need to be confirmed in a larger trial. CLINICAL TRIAL REGISTRATION: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02808767.

1st Department of Internal Medicine Cardioangiology ICRC Faculty of Medicine of Masaryk University and St Anne's University Hospital Brno Czech Republic

1st Department of Internal Medicine University Hospital Hradec Kralove Charles University Prague Faculty of Medicine in Hradec Kralove Czech Republic

1st Internal Cardiology Clinic University Hospital Olomouc Olomouc Czech Republic

2nd Department of Medicine Department of Cardiovascular Medicine 1st Faculty of Medicine Charles University Prague and General University Hospital Prague Prague Czech Republic

AGEL Research and Training Institute Trinec Branch Cardiovascular Center Podlesi Hospital Trinec Czech Republic

Cardiocenter Department of Cardiology Regional Hospital Ceske Budejovice Czech Republic

Cardiocenter Hospital Na Homolce Prague Czech Republic

Cardiocenter Regional Hospital Karlovy Vary Czech Republic

Cardiology Centre AGEL Pardubice Czech Republic

Cardiovascular Department University Hospital Ostrava Ostrava Czech Republic

Department of Cardiology Krajska zdravotni a s Masaryk Hospital and UJEP Usti nad Labem Czech Republic

Department of Cardiology University Hospital and Faculty of Medicine in Pilsen Charles University Prague Czech Republic

Department of Internal Medicine and Cardiology Faculty of Medicine of Masaryk University and University Hospital Brno Brno Czech Republic

From Cardiocenter 3rd Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady Prague Czech Republic

Institute of Biostatistics and Analyses at the Faculty of Medicine and the Faculty of Science of the Masaryk University Brno Czech Republic

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