Ticagrelor and prasugrel are independent predictors of improved long-term survival in ACS patients

Eur J Clin Invest. 2020 Nov;50(11):e13304. doi: 10.1111/eci.13304. Epub 2020 Sep 9.


Aim: To investigate the long-term clinical benefit of dual antiplatelet therapy with potent P2Y12 inhibitors compared to clopidogrel in patients with acute coronary syndrome (ACS).

Methods: In this prospective multicenter observational study, we enrolled 708 patients with ACS treated with clopidogrel (n = 137), ticagrelor (n = 260) or prasugrel (n = 311). Major adverse cardiac events (MACE; over 1 year) and long-term mortality (median: 5.6 years; interquartile range [IQR] 4.9-6.5 years) were assessed. Multiple electrode aggregometry (MEA) was used to measure adenosine diphosphate (ADP)- and arachidonic acid (AA)-induced platelet aggregation.

Results: Type of P2Y12 inhibitor emerged as an independent predictor of long-term mortality and MACE: patients treated with potent platelet inhibitors prasugrel or ticagrelor were at lower risk for long-term mortality (adjusted hazard ratio [HR] = 0.44; 95% CI: 0.22-0.92; P = .028) or MACE (adjusted HR = 0.38; 95% CI: 0.20-0.73; P = .004) than those treated with clopidogrel independent from clinical risk factors. In contrast, the efficacy of clopidogrel decreased with increasing severity of ACS: platelet aggregation was 37% higher in patients with ST segment elevation myocardial infarction (STEMI) and 25% higher in patients with non-ST elevation myocardial infarction (non-STEMI) compared to patients with unstable angina (P = .039). Patients with diabetes achieved less potent ADP- and AA-induced platelet inhibition under clopidogrel, compared to patients without diabetes (P = .045; P = .030, respectively).

Conclusion: In the setting of ACS, treatment with ticagrelor or prasugrel reduced long-term mortality and 1-year MACE as compared to clopidogrel.

Keywords: MEA; clopidogrel; mortality; platelets; prasugrel; ticagrelor.

Publication types

  • Observational Study

MeSH terms

  • Acute Coronary Syndrome / drug therapy*
  • Adenosine Diphosphate
  • Aged
  • Arachidonic Acid
  • Aspirin / therapeutic use
  • Cardiovascular Diseases / mortality
  • Clopidogrel / therapeutic use*
  • Dual Anti-Platelet Therapy / methods
  • Female
  • Humans
  • Male
  • Middle Aged
  • Mortality*
  • Myocardial Infarction / epidemiology
  • Platelet Aggregation Inhibitors / therapeutic use*
  • Platelet Function Tests
  • Prasugrel Hydrochloride / therapeutic use*
  • Prognosis
  • Proportional Hazards Models
  • Prospective Studies
  • Secondary Prevention
  • Stroke / epidemiology
  • Survival Rate
  • Ticagrelor / therapeutic use*


  • Platelet Aggregation Inhibitors
  • Arachidonic Acid
  • Adenosine Diphosphate
  • Clopidogrel
  • Prasugrel Hydrochloride
  • Ticagrelor
  • Aspirin