Do you favor ticagrelor or prasugrel first-line for the treatment of ACS with planned PCI, provided no contraindications to either agent?

The data suggest that ticagrelor and prasugrel are preferred over clopidogrel in ACS, albeit with increased hazard of bleeding complications. In one of the few head-to-head comparison trials in ACS, ISAR-REACT 5, prasugrel had increased efficacy over ticagrelor. Based on the best available data, it is likely that prasugrel carries a stronger antiplatelet effect compared to ticagrelor. The issue (and perhaps one of the reasons that ticagrelor has a greater market share of use for ACS in the US) i...

I prefer Prasugrel based on the latest data from ISAR-REACT 5 trial. I almost never use ticagrelor as it is expensive and there are significant side effects (Shortness of breath being the most common).

Assuming this question relates to oral, non-ASA antiplatelet therapies, ticagrelor is a fast onset, high antiplatelet efficacy, non-hepatic first pass requiring (can be given per rectal route if needed in cases of vomiting, etc.), comparative offset agent. It’s adenosine reuptake-related SOB effects (1 in 7), and its 2-4% incidence in bradycardia, in addition to its slightly higher bleeding risk, somewhat temper the enthusiasm for its use. Prasugrel is thus favored… unless one needs a fast onset...

Prasugrel has better data, but is limited by its prolonged half-life and cerebrovascular accident (CVA) or age restrictions. People seem to tolerate this medication much better, and it is more cost-efficient.