Comparative Efficacy and Safety of Ticagrelor and Prasugrel in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Clinical Trials.

Acute coronary syndrome (ACS) remains a leading cause of morbidity and mortality worldwide despite advances in percutaneous coronary intervention (PCI) and pharmacotherapy. We searched PubMed, Web of Science, and Cochrane CENTRAL for trials comparing prasugrel with ticagrelor in adults with ACS undergoing PCI. The primary outcome was all-cause mortality, while secondary outcomes included cardiovascular death, myocardial infarction, composite ischemic events, stent thrombosis, stroke, and bleeding events. Three randomized controlled trials and one post hoc study were selected, comprising 10,480 patients. All-cause mortality was similar between prasugrel and ticagrelor [RR 0.95 (95% CI: 0.75, 1.20); P = 0.66; I ² = 20%]. Prasugrel and ticagrelor also showed comparable risks of cardiovascular death [RR 1.00 (95% CI: 0.80, 1.26); P = 0.98; I ² = 0%], myocardial infarction [RR 0.94 (95% CI: 0.64, 1.39); P = 0.77; I ² = 67%], composite ischemic events [RR 1.01 (95% CI: 0.73, 1.41); P = 0.94; I ² = 80%], stent thrombosis [RR 0.93 (95% CI: 0.52, 1.65); P = 0.80; I ² = 59%], and stroke [RR 1.04 (95% CI: 0.67, 1.61); P = 0.86; I ² = 0%]. Major bleeding [RR 0.99 (95% CI: 0.77, 1.27); P = 0.91; I ² = 20%] and minor bleeding [RR 0.95 (95% CI: 0.76, 1.19); P = 0.67; I ² = 64%] were also comparable between groups. Overall, prasugrel and ticagrelor demonstrated similar efficacy and safety in patients with ACS undergoing PCI. These findings support an individualized approach to P2Y12 inhibitor selection based on patient characteristics, contraindications, tolerability, and adherence considerations rather than a preference for either agent.