Focus

• Comfort• Cost• Side Effects

• MI Definition• Cancer• Uric Acid• Serum Creatinine

MI Definition

• CAMI – centrally adjudicated MIs– Someone that is NOT taking care of the patient– Universally increases the event rate

• SRMI – site reported myocardial infarctions– Someone that is taking care of the patient

MI Definition

CAMI

Prasugrel Clopidogrel Difference HR P-value

475 620 145 0.76 <0.001

SRMI

Prasugrel Clopidogrel Difference HR P-value

226 298 72 0.76 0.08

Thromb Haemost 2012; 108: 412–414

TRITON

MI Definition

CAMI

Ticagrelor Clopidogrel Difference HR P-value

504 593 89 0.84 <0.001

SRMI

Ticagrelor Clopidogrel Difference HR P-value

504 548 44 0.92 0.095

Thromb Haemost 2012; 108: 412–414

PLATO

Probability of all 45 undiagnosed MIs belonging to the clopidogrel arm is 0.0000000000002

One in 5 trillion!!

Cancer – Prasugrel

Arch Intern Med. 2010;170(12):1078-1080.

Measure of Impact

Solid Cancer (N) Total (N)

Prasugrel 92 6813

Clopidogrel 64 6795

Prasugrel = 14 events per 1000 patientsClopidogrel = 9 events per 1000 patients

Prasugrel causes 5 events per 1000 patients

Arch Intern Med. 2010;170(12):1078-1080.

Uric Acid

NEJM 2009;361:1045-57.

PLATO

Renal Function

NEJM 2009;361:1045-57.

PLATO

One more thing...

MI, stroke, CV DeathTicagrelor 11.9%, Clopidogrel 9.6%

HR 1.25; 95% CI 0.93-1.67

NEJM 2009;361:1045-57.

Conclusion

• Prasugrel – Causes bleeding, cancer, and didn’t really statistically reduce MI

• Ticagrelor – Causes dyspnea, ventricular pauses, elevated uric acid, elevated SCr, and didn’t really statistically reduce MI

• Clopidogrel is Big Bird