Comparative Efficacy and Safety of Ticagrelor and Prasugrel in Acute Coronary Syndrome: A Meta-Analysis of Randomized controlled trials

Background Acute coronary syndrome (ACS) remains a leading cause of morbidity and mortality worldwide despite advances in percutaneous coronary intervention (PCI) and pharmacotherapy. Methods We searched PubMed, Web of Science, and Cochrane CENTRAL for RCTs comparing prasugrel with ticagrelor in adults with ACS undergoing PCI. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular death, myocardial infarction, composite ischemic events, stent thrombosis, stroke, and bleeding events. Results Four randomized controlled trials 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; I² = 20%]. Prasugrel and ticagrelor also showed comparable risks of cardiovascular death [RR 1.00 (95% CI: 0.80, 1.26); P = 0.98; I² = 0%], myocardial infarction [RR 0.94 (95% CI: 0.64, 1.39); P = 0.77; I² = 67%], composite ischemic events [RR 1.01 (95% CI: 0.73, 1.41); P = 0.94; I² = 80%], stent thrombosis [RR 0.93 (95% CI: 0.52, 1.65); P = 0.80; I² = 59%], and stroke [RR 1.04 (95% CI: 0.67, 1.61); P = 0.86; I² = 0%]. Major bleeding [RR 0.99 (95% CI: 0.77, 1.27); P = 0.91; I² = 20%] and minor bleeding [RR 0.95 (95% CI: 0.76, 1.19); P = 0.67; I² = 64%] were also comparable between groups. Conclusion 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.