I have questions about the data on efficacy.  I don't think the doses used were equipotent doses.  I also gree that this could cause a lot of confusion especially in the emergent care setting.  It is not easy to elicit TIA or Stroke history in the ER.  And I have concerns about the bleeding.  I would like to see some postmarketing data.  For now I will continue to use Plavix unless there are contraindications to its use.

I too have major concerns regarding the efficacy vs. safety profile of this drug, especially in light of the major black box warning in its labeling.  I also question the results seen in the TRITON TIMI-38 trial, due to the fact that patients in the trial were not loaded upstream in the management of ACS as is typically done with Plavix, many cases were not treated until after the procedures were done.  Consider that peri-procedural "MIs" in the Plavix arm drove the efficacy results to favor prasugrel and it makes you wonder what results you would get when Plavix is used as usual.  PCI-CURE may shed light on this.  Another concern in the acute setting, previously noted is the ability to ascertain stroke/TIA hx under the circumsatnces.  Additionally, where do all the so-called "silent" strokes/TIA fit into the picture.

There is definitely a role for prasugrel, particularly in high-risk diabetics, clopidogrel failure, allergy, non-responders.  It will be some time before this novel agent can be used with the confidence that Plavix is currently used.