***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES The objective of this study was to characterize the bleeding , transfusion , and other outcomes of patients related to the timing of prasugrel or clopidogrel withdrawal before coronary artery bypass grafting ( CABG ) . BACKGROUND There is little evidence to guide clinical decision making regarding the use of prasugrel in patients who may need urgent or emergency CABG . Experience with performing CABG in the presence of clopidogrel has raised concern about perioperative bleeding complications that are unresolved . METHODS A subset of the TRITON-TIMI 38 study ( Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis In Myocardial Infa rct ion 38 ) , in which patients with acute coronary syndrome were r and omized to treatment with aspirin and either clopidogrel or prasugrel , underwent isolated CABG ( N = 346 ) . A supplemental case report form was design ed and administered , and the data combined with the existing TRITON-TIMI 38 data base . Baseline imbalances were corrected for using elements of the European System for Cardiac Operative Risk Evaluation and The Society of Thoracic Surgeons predictive algorithm . RESULTS A significantly higher mean 12-h chest tube blood loss ( 655 ± 580 ml vs. 503 ± 378 ml ; p = 0.050 ) was observed with prasugrel compared with clopidogrel , without significant differences in red blood cell transfusion ( 2.1 U vs. 1.7 U ; p = 0.442 ) or the total donor exposure ( 4.4 U vs. 3.0 U ; p = 0.463 ) . All-cause mortality was significantly reduced with prasugrel ( 2.31 % ) compared with 8.67 % with clopidogrel ( adjusted odds ratio : 0.26 ; p = 0.025 ) . CONCLUSIONS Despite an increase in observed bleeding , platelet transfusion , and surgical re-exploration for bleeding , prasugrel was associated with a lower rate of death after CABG compared with clopidogrel INTRODUCTION The antiplatelet effect of st and ard or increased clopidogrel doses in patients with ST- segment elevation acute myocardial infa rct ion ( STEMI ) has never been studied . In this study we compared the antiplatelet effect of a 75 mg daily maintenance dose of clopidogrel with 150 mg in patients with STEMI undergoing primary percutaneous coronary intervention ( PCI ) . MATERIAL S AND METHODS Fifty-four patients with STEMI undergoing PCI were r and omly allocated to receive either 75 mg/day clopidogrel ( group 1 ) or 150 mg/day ( group 2 ) for 1 month . Platelet function , measured by 5 different assays , was determined at 3 time points : 38+/-8 hours after the procedure , 1 week and 1 month after r and omization . RESULTS In group 1 , mean + /- SD platelet reactivity index ( PRI ) measured with the VASP assay was 57.7+/-15.7 % and 46.9+/-15.7 % at 1 week and 1 month , respectively , compared to 38.8+/-15.7 % and 34.9+/-12.6 % in group 2 ( p=0.0001 ) . Same results were observed for light transmittance aggregometry , whole blood aggregometry and VerifyNow , but not for thromboelastometry . In contrast to what may be expected , the 75 mg daily maintenance dose took longer than 1-week to provide the full clopidogrel antiplatelet effect . Furthermore , patients in group 2 had a nearly 50 % reduction in C-reactive protein levels both at 1 week and 1 month . CONCLUSION In patients with STEMI and poor responsiveness to clopidogrel  a 150 mg daily maintenance dose of clopidogrel is associated with a significant reduction of platelet aggregation and a trend towards reduced inflammation The r and omized TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with Prasugrel-Thrombolysis In Myocardial Infa rct ion ( TRITON-TIMI ) 38 trial compared prasugrel and clopidogrel in patients with acute coronary syndrome undergoing percutaneous coronary intervention ( PCI ) . Patients treated with prasugrel had fewer ischemic events but more procedure-related bleeding . In the present study , we aim ed to determine the effect of bivalirudin on bleeding in patients treated with prasugrel .  A total of 692 patients with consecutive acute coronary syndrome underwent PCI with stent implantation and were anticoagulated with bivalirudin .  The patients were divided into 2 groups according to the antiplatelet regimen ( clopidogrel or prasugrel ) chosen during or just after PCI . The bleeding complications during hospitalization were tabulated . Ischemic events were analyzed during hospitalization and at 30 days . Prasugrel was used in 96 patients ( 13.9 % ) and clopidogrel in 596 ( 86.1 % ) . The clinical and procedural characteristics were similar , although the clopidogrel patients more often reported systemic hypertension ( p = 0.01 ) , previous PCI ( p < 0.001 ) , and chronic renal insufficiency ( p = 0.05 ) . During hospitalization , the bleeding and ischemic complication rates were similar and low in both groups ( major in-hospital complications 4.2 % for clopidogrel vs 2.1 % for prasugrel , p = 0.6 ; Thrombolysis In Myocardial Infa rct ion major bleeding 2.5 % vs 2.1 % , p = 1.00 ; Thrombolysis In Myocardial Infa rct ion minor bleeding 4.2 % vs 5.2 % , p = 0.6 ) . At 30 days , no differences were found in ischemic events between both groups ( target vessel revascularization/major adverse cardiac events 5.4 % vs 2.1 % , p = 0.2 ) . In conclusion , prasugrel , when given after bivalirudin as the intraprocedural antithrombin agent for patients with acute coronary syndrome undergoing PCI , is as safe and effective as clopidogrel Background Although unstable coronary artery disease is the most common reason for admission to a coronary care unit , the long-term prognosis of patients with this diagnosis is unknown . This is particularly true for patients with diabetes mellitus , who are known to have a high morbidity and mortality after an acute myocardial infa rct ion . Methods and Results Prospect ively collected data from 6 different countries in the Organization to Assess Strategies for Ischemic Syndromes ( OASIS ) registry were analyzed to determine the 2-year prognosis of diabetic and nondiabetic patients who were hospitalized with unstable angina or non – Q-wave myocardial infa rct ion . Overall , 1718 of 8013 registry patients ( 21 % ) had diabetes . Diabetic patients had a higher rate of coronary bypass surgery  than nondiabetic patients ( 23 % versus 20 % , P < 0.001 ) but had similar rates of catheterization and angioplasty . Diabetes independently predicted mortality ( relative risk [ RR ] , 1.57 ; 95 % CI , 1.38 to 1.81;P < 0.001 ) , as well as cardiovascular death , new myocardial infa rct ion , stroke , and new congestive heart failure . Moreover , compared with their nondiabetic counterparts , women had a significantly higher risk than men ( RR , 1.98 ; 95 % CI , 1.60 to 2.44 ; and RR , 1.28 ; 95 % CI , 1.06 to 1.56 , respectively ) . Interestingly , diabetic patients without prior cardiovascular disease had the same event rates for all outcomes as nondiabetic patients with previous vascular disease . Conclusions Hospitalization for unstable angina or non – Q-wave myocardial infa rct ion predicts a high 2-year morbidity and mortality ; this is especially evident for patients with diabetes . Diabetic patients with no previous cardiovascular disease have the same long-term morbidity and mortality as nondiabetic patients with established cardiovascular disease after hospitalization for unstable coronary artery disease In acute coronary syndromes ( ACS ) , a dual antiplatelet regimen with an adenosine diphosphate ( ADP ) receptor antagonist plus aspirin has become the cornerstone of treatment . The third-generation thienopyridine prasugrel and the cyclopentyl-triazolo-pyrimidine ticagrelor provide a greater , more rapid and consistent platelet inhibition compared to their predecessor clopidogrel . Based on their advantages over clopidogrel in two l and mark studies , both drugs received a class I recommendation for their use in ACS patients with and without ST segment elevation . Due to differences in ACS population s and conditions investigated , the relative merits of ticagrelor versus prasugrel in the treatment of ACS patients with planned invasive strategy can not be reliably estimated from independent trials . To date , no direct head-to-head comparison of ticagrelor and prasugrel in terms of clinical outcome exists . The aim of this multicenter , r and omized , open-label trial is to assess whether ticagrelor is superior to prasugrel in ACS patients with planned invasive strategy Background —Ticagrelor and prasugrel provide stronger platelet inhibition compared with clopidogrel . Direct pharmacodynamic comparison between them has not yet been reported in ST-segment – elevation myocardial infa rct ion patients . Methods and Results —In a prospect i ve , single-center , single-blind study , 55 out of 117 ( 47 % ) screened consecutive ST-segment – elevation myocardial infa rct ion patients undergoing primary percutaneous coronary intervention were r and omized to either ticagrelor 180 mg loading followed by 90 mg bid , or prasugrel 60 mg loading followed by 10 mg od for 5 days . Platelet reactivity ( PR ) was assessed with the VerifyNow P2Y12 function assay and the Multiplate Analyzer at 0 , 1 , 2 , 6 , 24 hours , and 5 days postr and omization . The primary end point , PR with VerifyNow at hour 1 , did not differ significantly between patients r and omized to ticagrelor versus prasugrel ( 257.3 P2Y12 reaction unit [ PRU ] , 95 % CI 230.8–283.8 versus 231.3 PRU , 95 % CI 205.3–257.4 ; P=0.2 ) . PR did not differ at 2 , 6 , and 24 hours , although at day 5 it was lower with ticagrelor than prasugrel ( 25.6 PRU , 95 % CI 12.3–38.9 versus 50.3 PRU , 95 % CI 36.4–64.1 ; P=0.01 ) . At hour 2 , high on-treatment PR rates ( cutoff 208 PRU ) were 46.2 % and 34.6 % for ticagrelor and prasugrel , respectively , decreased significantly thereafter , whereas did not differ significantly between the 2 agents at all the time points of the study . Conclusions —In patients with ST-segment – elevation myocardial infa rct ion undergoing primary percutaneous coronary intervention , both ticagrelor and prasugrel exhibit an initial delay in the onset of their antiplatelet action . Ticagrelor did not appear superior to prasugrel in reducing PR during the first 24 hours of ST-segment – elevation myocardial infa rct ion . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT01463163 BACKGROUND Recurrent ischemic events occurred even during routine use of 75 mg clopidogrel in addition to aspirin , that indicated a potentially insufficient maintenance dosage of clopidogrel . The aim of the present study was to evaluate the short-term efficacy and safety of a 150 mg maintenance dose of clopidogrel following a 600 mg loading dose in patients with an acute coronary syndrome ( ACS ) undergoing drug eluting stent ( DES ) implantation . METHODS Between November 2005 and November 2006 , a total of 813 consecutive ACS patients undergoing DES implantation were enrolled . A 600 mg loading dose was administered before percutaneous coronary intervention ( PCI ) and patients were r and omized to receive clopidogrel 75 mg or 150 mg for 30 days in addition to 300 mg aspirin daily . Primary end points were the composite of cardiac death , non-fatal myocardial infa rct ion ( MI ) and urgent target vessel revascularization ( UTVR ) . Secondary end points included stent thrombosis ( ST ) , major and minor bleeding events at 30 days . RESULTS At a follow-up period of 30 days , 4 ( 1.0 % ) patients in the 150 mg group and 9 ( 2.2 % ) patients in the 7 
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A key strength of the review is that it demonstrates the cost-effectiveness of prasugrel compared with clopidogrel using the generic price of clopidogrel .
Although the report demonstrates the cost-effectiveness of prasugrel compared with clopidogrel at a threshold of £ 20,000 to £ 30,000 per QALY gained , the long-term modelling is vulnerable to major assumptions regarding long-term gains .