Prasugrel , Ticagrelor and Clopidogrel in primary percutaneous coronary intervention : a comparative analysis Brief title : Prasugrel , Ticagrelor and Clopidogrel in primary PCI

Objectives: Prasugrel and ticagrelor both reduce ischaemic endpoints in high -risk acute coronary syndromes, compared to clopidogrel. However, comparative outcomes of these two newer drugs in the context of primary PCI for ST elevation MI (STEMI) remains unclea r. W sought to examine this question using the British Cardiovascular Interventional Soci ety national database in patients undergoing primary PCI for STEMI. Methods: Data from January 2007 to December 2014 was used to compare use of P 2Y12 antiplatelet drugs in primary PCI in > 89,000 patients. Statistical modeling, involvi g propensity matching, multivariable logistic regression (MLR) and proportional hazar ds modeling, was used to study the association of different antiplatelet drug use wi th all-cause mortality. Results: In our main MLR analysis, prasugrel was associated with significantly lowe r mortality than clopidogrel at both 30 -days (OR 0.87 95% CI 0.78 -0.97, p=0.014) and 1 -year (OR 0.89 95% CI 0.82-0.97, P=0.011) post PCI. Ticagrelor was not associated with any significant differences in mortality compared to clopidogrel at either 30 -days (OR 1.07 95%CI 0.95 -1.21, P=0.237) or 1-year (OR 1.058 95%CI 0.96 -1.16, P=0.247). Finally, ticagrelor was associated with significantly higher morta lity than prasugrel at both time points (30 -days, OR 1.22 95%CI 1.03-1.44, P=0.020; 1-year OR 1.19 95% CI 1.04-1.35, P=0.01). Conclusions: In a cohort of over 89,000 patients undergoing primary PCI for STEMI in the UK, prasugrel is associated with a lower 30-day and 1year mortality than clopidogrel and ticagrelor. Given that an adequately powered comparative randomised trial is unlikely to be performed, these data may have implications for routine care.