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Prasugrel lowered main cardiovascular occasions to the identical extent as ticagrelor however with decrease main bleeding after coronary stenting in sufferers with acute coronary syndromes, in keeping with outcomes from the SWITCH SWEDEHEART trial introduced in a Scorching Line session as we speak at ESC Congress 2026 and printed concurrently within the New England Journal of Medication.
A potent P2Y12 inhibitor plus aspirin is the usual of care to forestall main cardiovascular occasions in sufferers with acute coronary syndromes (ACS) who’ve undergone percutaneous coronary intervention (PCI).
The relative deserves of two potent P2Y12 inhibitors – prasugrel and ticagrelor – have been extensively debated, famous Principal Investigator of SWITCH SWEDEHEART, Professor Elmir Omerovic from Sahlgrenska College Hospital, Gothenburg, Sweden: “Within the ISAR-REACT 5 trial, a prasugrel-based technique was superior to a ticagrelor-based technique for main cardiovascular occasions with out a rise in main bleeding, however whether or not the identical distinction can be seen in an unselected inhabitants in on a regular basis medical follow was unknown,” he defined, persevering with, “A number of Swedish healthcare areas determined to undertake prasugrel because the default P2Y12 inhibitor for ACS and we used this alteration as the premise for a practical analysis of a default prasugrel coverage in contrast with ticagrelor utilizing the established SWEDEHEART registry platform.” The 2023 ESC Pointers already state that prasugrel needs to be thought of in place of ticagrelor for ACS sufferers who bear PCI (class IIa, Degree B). SWITCH SWEDEHEART provides pragmatic, registry-based randomized proof in an unselected inhabitants.
The registry-based SWITCH SWEDEHEART trial randomized areas moderately than particular person sufferers: seven Swedish areas in three clusters switched their default P2Y12 inhibitor from ticagrelor to prasugrel at staggered, randomly assigned occasions (a stepped-wedge design).
The trial included all 17,095 consecutive adults with ACS present process PCI, together with aged sufferers and people with prior stroke or a sign for oral anticoagulation, who’re often excluded from trials. Below the ticagrelor coverage, 9,444 sufferers have been beneficial to obtain ticagrelor 90 mg twice day by day. Below the prasugrel coverage, 7,651 sufferers have been beneficial to obtain prasugrel 10 mg as soon as day by day lowered to five mg as soon as day by day in sufferers aged 75 years or older, or weighing lower than 60 kg, as per the label.
The first endpoint of demise from any trigger, myocardial infarction or stroke at one yr occurred in comparable proportions of sufferers with every therapy coverage: 11.1% of sufferers underneath the prasugrel coverage and 11.8% underneath the ticagrelor coverage (adjusted odds ratio [OR] 0.90; 95% confidence interval [CI] 0.77 to 1.06). The person elements of the first endpoint didn’t differ.
Of word, the chance of main bleeding at one yr was considerably decrease with the prasugrel coverage in contrast with the ticagrelor coverage (4.2% vs. 4.4%; OR 0.80; 95% CI 0.64 to 0.99).
Commenting on the primary of SWITCH SWEDEHEART’s most important conclusions, Professor Omerovic stated: “Within the largest randomized comparability thus far, prasugrel supplied comparable safety in opposition to main cardiovascular occasions, however with a sign towards much less bleeding and decrease price – a probably essential consideration for sufferers and healthcare programs.” Secondly, he famous the success of the novel methodology: “We have been in a position to run a big policy-level, randomised trial inside a nationwide registry at a fraction of the price of a standard trial, evaluating the influence of two therapies and an essential healthcare change in real-world sufferers. Our trial represents a mannequin of medical proof technology that could possibly be used to nice impact throughout cardiology and in lots of different areas of healthcare.“
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