Prasugrel in the management of acute coronary syndromes: a systematic review.

BACKGROUND AND

objectivePrasugrel is a third-generation thienopyridine P2Y12 receptor inhibitor with superior pharmacological properties compared with clopidogrel, offering faster onset, greater potency, and more predictable platelet inhibition. This review critically evaluates the evidence base underpinning the rational use of prasugrel in acute coronary syndromes (ACS), encompassing its pharmacology, comparative efficacy across clinical subtypes, safety profile, special population considerations, and place in contemporary clinical practice.

methodsA systematic search was employed to abstract studies related to the rational use of prasugrel in ACS from the literature. All English studies from 2010 to 2026 focusing on the effectiveness and safety profile of the agent were abstracted after a search in Google Scholar, PubMed, Scopus, Web of Science, and MEDLINE. The PubMed/MEDLINE component of the search was executed on 17 July 2026 using the strategy ("prasugrel"[All Fields] OR "prasugrel hydrochloride"[MeSH Terms]) AND ("coronary"[All Fields] OR "heart"[MeSH Terms]) AND ("syndrome"[MeSH Terms]) AND ("infarction"[MeSH Terms]); this returned 779 records, which were reduced to 607 after limiting to English-language human studies published between 2010 and 2026, and to 202 reports meeting the prioritised study-design criteria (randomised controlled trials, meta-analyses, systematic reviews, and clinical practice guidelines) that were assessed in full text. The numbers of records identified, screened, assessed for eligibility, and included are summarised in the PRISMA 2020 flow diagram (Fig. 1), and the full electronic search string with translated field tags is provided as Supplementary Material (Table S1). Case reports, editorials, corrigenda, unpublished data, letters, and opinion articles were excluded from the analysis. Selected high-quality observational studies and post-marketing registries were, however, additionally incorporated to inform real-world effectiveness and special-population questions for which randomised data are limited or under-powered. Evidence was collated narratively and presented in tabular format. The quality of evidence for the trials was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.

resultsPrasugrel offers clinically meaningful reductions in ischaemic events compared with clopidogrel in ACS patients undergoing percutaneous coronary intervention and demonstrated superiority over ticagrelor in major trials. Careful patient selection is mandatory, with absolute contraindications including prior stroke or transient ischaemic attack and active pathological bleeding.

conclusionsIn eligible ACS patients proceeding to intervention, prasugrel is the preferred or co-preferred P2Y12 inhibitor in contemporary European and American guidelines. Platelet function testing-guided de-escalation to clopidogrel provides a validated alternative strategy for patients at elevated bleeding risk during the maintenance phase of therapy.