Low-dose prasugrel versus standard-dose ticagrelor in east Asian patients with acute coronary syndrome

Low-dose prasugrel demonstrated a similar effectiveness profile to clopidogrel in East Asian ACS patients, but its comparison with another new-generation potent P2Y12 inhibitor, ticagrelor, remains unclear. To compare the effectiveness and safety of low-dose prasugrel against those of standard-dose ticagrelor in East Asian patients with ACS. This retrospective cohort study used Taiwan’s National Health and Welfare Database. This study included ACS patients who underwent percutaneous coronary intervention and, at discharge between January 1, 2018 and December 31, 2020, were prescribed with low-dose prasugrel plus aspirin or standard-dose ticagrelor plus aspirin. Stabilized inverse probability of treatment weighting was used to balance the covariates across these two groups. The primary effectiveness outcome was a composite of acute myocardial infarction, ischemic stroke, and cardiovascular death; the secondary effectiveness outcome was each of the individual components of the primary outcome, transient ischemic attack, and repeat revascularization. The primary safety outcome was a composite of intracranial hemorrhage and gastrointestinal bleeding, and the two secondary safety outcomes were intracranial hemorrhage and gastrointestinal bleeding. A total of 24,807 patients were included in this study. Among them, 1,493 were low-dose prasugrel users and 23,314 were standard-dose ticagrelor users. No significant differences were found in primary effectiveness [HR: 0.97 (0.74–1.28)] or primary safety outcomes [HR: 1.22 (0.73–2.01)] between the two study groups. For East Asian patients with ACS, low-dose prasugrel provides comparable effectiveness without increasing bleeding risk compared to standard-dose ticagrelor. Low-dose prasugrel may be an appropriate alternative for East Asian populations. Effectiveness and safety of low-dose prasugrel in a real-world East Asian population are not fully understood, particularly in comparison to another potent P2Y12 inhibitor, ticagrelor. This study aim to evaluate whether low-dose prasugrel use in an East Asian population can maintain its effectiveness and prevent excessive bleeding compared to standard-dose ticagrelor in ACS patients undergoing PCI. Our findings suggest that for East Asian patients with ACS, low-dose prasugrel can maintain effectiveness without increasing bleeding risk compared to standard-dose ticagrelor. Low-dose prasugrel may be an appropriate alternative for East Asian populations. Further research could explore the correlation between the platelet function testing results and clinical outcomes in East Asian patients with ACS using low-dose prasugrel.