Ticagrelor versus prasugrel following PCI in acute coronary syndromes and high-risk coronary artery disease: A meta-analysis of one-year randomized trial outcomes

Background Guidelines recommend potent P2Y12 inhibitors over clopidogrel following percutaneous coronary intervention. Whether ticagrelor- or prasugrel-based dual antiplatelet therapy (DAPT) provides superior clinical outcomes following percutaneous coronary intervention (PCI) remains uncertain, particularly across acute coronary syndromes (ACS) and high-risk coronary artery disease (CAD) populations. Methods We searched databases for randomized controlled trials comparing ticagrelor- and prasugrel-based DAPT in patients with CAD undergoing PCI with 1-year follow-up. The primary outcomes were major adverse cardiovascular events (MACE) and all-cause mortality. Secondary outcomes included cardiovascular death, myocardial infarction, stroke, stent thrombosis, and major bleeding. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled using random-effects models. Sensitivity analyses were performed in ACS populations. Results Three trials randomized a total of 7048 patients. In the primary analysis, prasugrel-based therapy was not associated with a statistically significant reduction in MACE compared with ticagrelor-based therapy (HR = 0.83; 95% CI: 0.67–1.03; p = 0.09). All-cause mortality (HR = 0.86; 95% CI: 0.68–1.08; p = 0.20), cardiovascular death (HR = 0.93; 95% CI: 0.72–1.21; p = 0.60), myocardial infarction (HR = 0.80; 95% CI: 0.56–1.14; p = 0.22), stroke (HR = 1.04; 95% CI: 0.63–1.73; p = 0.87), stent thrombosis (HR = 0.70; 95% CI: 0.45–1.11; p = 0.13), and major bleeding (HR = 0.89; 95% CI: 0.68–1.17; p = 0.41) were comparable between strategies. ACS-restricted sensitivity analyses demonstrated consistent findings across all outcomes. Conclusions Among patients with ACS and high-risk CAD undergoing PCI, current randomized evidence does not establish conclusive superiority between ticagrelor- and prasugrel-based DAPT for 1-year ischemic or bleeding endpoints.