- Question
- In patients with unstable angina or non-ST-elevation myocardial infarction managed without revascularization, does more intensive platelet inhibition with prasugrel reduce ischemic events compared with clopidogrel?
- Design
- Randomized, double-blind, phase 3 trial with 9326 patients per the registry. The primary analysis included 7243 patients under 75 years of age, treated for up to 30 months with a median follow-up of 17 months.
- Population
- Patients with non-ST-elevation acute coronary syndrome (unstable angina or non-ST-elevation myocardial infarction) managed medically without revascularization and receiving aspirin. Those aged 75 or older were assessed in a secondary analysis.
- Intervention
- Prasugrel 10 mg daily plus low-dose aspirin in patients under 75; prasugrel 5 mg daily in patients aged 75 or older.
- Control
- Clopidogrel 75 mg daily plus low-dose aspirin.
- Primary outcome
- Composite of cardiovascular death, myocardial infarction, or stroke, assessed in patients under 75 years of age.
- Results
- The primary end point occurred in 13.9% with prasugrel and 16.0% with clopidogrel (HR 0.91; 95% CI 0.79 to 1.05; P=0.21), a nonsignificant difference; results were similar in the overall population. The prespecified analysis of recurrent ischemic events suggested lower risk with prasugrel in patients under 75 (HR 0.85; 95% CI 0.72 to 1.00; P=0.04).
- Safety
- Rates of severe and intracranial bleeding were similar between groups across all age groups. There were no differences in nonhemorrhagic serious adverse events, except for a higher frequency of heart failure in the clopidogrel group.
- Conclusion
- In patients with non-ST-elevation acute coronary syndrome managed without revascularization, prasugrel did not significantly reduce the primary end point compared with clopidogrel, with similar bleeding risk.
- Why it matters
- The trial showed that in this population without revascularization, intensifying platelet inhibition with prasugrel did not demonstrate a clear benefit over clopidogrel on the main end point, limiting the rationale for preferring it in these patients.
Card generated automatically with AI from the abstract of the original publication and the trial registry; every figure was checked against those sources. It may contain errors: verify the data at the source before using it for clinical decisions.
Generated on October 10, 2026