Background: The ISAR-REACT 5 randomized trial compared the efficacy and safety of ticagrelor and prasugrel in patients with acute coronary syndrome (ACS) treated invasively. Our aim was to investigate the impact of ticagrelor and prasugrel on the incidence and pattern of repeat revascularizations in invasively treated patients with ACS. 

Methods: This post-hoc analysis of the ISAR-REACT 5 trial included all ACS patients who underwent percutaneous coronary intervention (PCI). Patients were split into two groups according to the assigned antiplatelet treatment. The primary outcome was the incidence of repeat revascularization (percutaneous or surgical) up to 12-month follow-up. Secondary outcomes were target vessel revascularization (TVR) and non-target vessel revascularization (NTVR). We also examined whether the repeat revascularization procedures were unplanned in nature.

Results: Of 3,377 ACS patients who received PCI, 1,676 were assigned to the ticagrelor and 1,701 to the prasugrel group. Compared to prasugrel, the incidence of repeat revascularization was significantly higher in patients treated with ticagrelor at 12 months (32.5% vs 29.7%, hazard ratio [HR]=1.14; 95% confidence interval [CI] 1.01-1.29, p= .034), mostly attributable to significantly more NTVR (26.6% vs. 24.1%, HR=1.15 [1.01-1.32], p= .042) in the ticagrelor group. There was a trend toward more unplanned repeat revascularization in patients receiving ticagrelor compared to prasugrel (6.8% vs. 5.2%, HR=1.32 [1.00-1.75], p= .051). The risk of TVR was not significantly different between treatment groups. 

Conclusions: In PCI-treated patients with ACS, prasugrel is associated with a significantly lower number of repeat revascularizations, mainly in remote coronary vessels, at 12 months compared to ticagrelor.