title: Among antithrombotic agents, prasugrel, but not ticagrelor, is associated with reduced 30 day mortality in patients with ST-elevated myocardial infarction.
abstract: BACKGROUND
  ST-elevated myocardial infarction (STEMI) holds the highest early mortality among patients with acute coronary syndromes. Despite numerous claims of clinical benefits and superiority over clopidogrel, there are no head-to-head outcome randomized clinical trials (RCTs) directly comparing novel antithrombotic agents in STEMI. Moreover, since most regulatory approvals are based on a single RCT's results, their meta-analyses are rare to compare death rates. We analyzed the 30-day mortality in STEMI patients who underwent percutaneous coronary intervention (PCI) and were treated with antithrombotic agents compared to clopidogrel as a reference.
  
  
  RESULTS
  Altogether, 10 RCT's and 1 retrospective study with a total number of 26,658 STEMI patients were included. Random-effects model with Mantel-Heanszel weighting was used to pool outcomes into a meta-analysis. Therapy with clopidogrel was associated with 2.76% 30-day STEMI mortality which was similar to that of ticagrelor (2.6%; OR=0.9395 [CI=0.76 to 1.17; p=0.58]), and for bivalirudin (2.8%; OR=1.02 [CI=0.82 to 1.27; p=0.86]), but was slightly higher for heparin (3.0%; OR=1.08 [CI=0.86 to 1.35; p=0.52]). There was a trend towards lower mortality after tirofiban (2.1%; OR=0.77 [CI=0.52 to 1.13; p=0.20]), and cangrelor (1.7%; OR=0.59 [CI=0.29 to 1.20; p=0.19]), although the sample size for both agents was woefully small. The only agent which offers a significant 30-day mortality benefit in STEMI was prasugrel with significant lowest 1.75% death rate (OR=0.63 [CI=0.46 to 0.86; p=0.03]).
  
  
  CONCLUSIONS
  Among antithrombotic agents, prasugrel, but not ticagrelor, offers significant 30-day mortality benefit over clopidogrel in PCI-treated STEMI patients justifying short-term use in such a high-risk population.
authors.affiliation: Johns Hopkins University, Towson, MD, USA. Electronic address: heartdrug@aol.com.
authors.forename: Victor L
authors.initials: VL
authors.lastname: Serebruany
authors.affiliation: Johns Hopkins University, Towson, MD, USA.
authors.forename: Vasily
authors.initials: V
authors.lastname: Cherepanov
authors.affiliation: Charles University, Prague, Czech Republic.
authors.forename: Ales
authors.initials: A
authors.lastname: Tomek
authors.affiliation: Dong-A University Medical Center, Busan, Republic of Korea.
authors.forename: Moo Hyun
authors.initials: MH
authors.lastname: Kim
mesh_terms: D000241:Adenosine / Q000031:analogs & derivatives* / Q000494:pharmacology; D000077144:Clopidogrel; D004562:Electrocardiography / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery; D017063:Outcome Assessment, Health Care; D062645:Percutaneous Coronary Intervention / Q000379:methods; D010975:Platelet Aggregation Inhibitors / Q000494:pharmacology; D000068799:Prasugrel Hydrochloride / Q000494:pharmacology*; D016032:Randomized Controlled Trials as Topic; D016019:Survival Analysis; D000077486:Ticagrelor; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000494:pharmacology
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine
keywords: Antithrombotics; Clinical trials; Clopidogrel; Mortality; Prasugrel; ST elevated myocardial infarction; Ticagrelor