Real-world in-hospital antiplatelet-switching strategy after coronary interventions: The SWITCH study
Real-life strategy of using ticagrelor or prasugrel for fast and reliable periprocedural antiplatelet inhibition followed by acute switch to long-term clopidogrel therapy was safe and efficacious.
- The acute switching strategy (before hospital discharge) appeared safe from a bleeding, reinfarction, stent thrombosis, and 30-day mortality perspective.
- The balance between efficacy and safety of ticagrelor and prasugrel vs effect of increased adherence to lower-cost clopidogrel therapy warrants further consideration.
Why This Matters
- Non-affordability due to higher cost of newer antiplatelet agents may lead to compliance concerns.
- There is a paucity of data on acute antiplatelet agent switching in the real-world clinical setting.
LARGE, RETROSPECTIVE, SINGLE-CENTER STUDY (N = 5,007)*
KEY INCLUSION CRITERIA
- Patients who underwent a PCI between January 1, 2013 and December 31, 2016
KEY EXCLUSION CRITERIA
- Patients who were prescribed ticlopidine (n = 18)
LOADING AND MAINTENANCE ANTIPLATELET AGENT: Patients were divided into 5 subgroups†
ENDPOINTS: 30-day all-cause mortality and bleeding events‡
Overall, 5,007 patients were included in the analysis
Prior to PCI: 54.8% of patients were preloaded with ticagrelor,
8.5% with prasugrel, and 36.7% with clopidogrel
SWITCH TO LONG-TERM CLOPIDOGREL THERAPY:
93% patients initially loaded
58% patients initially loaded
Significant differences in major bleeding (depending on antiplatelet management strategy; P <0.001)
Lowest bleeding rates: In patients pretreated with ticagrelor or prasugrel and switched to clopidogrel (0.9% and 0.8%, respectively)
Highest rates of major BARC 3a bleeding: In patients maintained on ticagrelor or clopidogrel (2.52% and 1.74%, respectively)§
30-DAY ALL-CAUSE MORTALITY:
30-day all-cause mortality rate: 1%
30-day all-cause mortality:Significantly lower in patients who underwent switching strategy vs those on clopidogrel therapy throughout hospitalization (P <0.001)
Highest all-cause mortality rates: In patients maintained on clopidogrel throughout index hospitalization (1.9%), followed by patients loaded with ticagrelor and then switched to clopidogrel (0.6%)
- Single-center, retrospective study with limited 30-day outcome data
- Baseline patient characteristics were not presented (these may have differedacross treatment arms)
- Rationale for selection and switching between P2Y12 inhibitors was at the treatingphysician’s discretion and not recorded
- Retrospective data abstraction from charts (UMass EMR)
* N = 5,007; University of Massachusetts Memorial Medical Center.
† Patients were divided into 5 subgroups based on choice of loading and maintenance antiplatelet agent: ticagrelor toticagre lor; ticagrelor to clopidogrel; prasugrel to prasugrel; prasugrel to clopidogrel; and clopidogrel to clopidogrel.
‡ 30-day all-cause mortality and bleeding events as defined by BARC.
§ After accounting for additional periprocedural use of intravenous GP IIb/ IIIa inhibitors, patients loaded with ticagrelor andswitched to clopidogrel had the lowest BARC 3a bleeding rates (0.75%) and patients maintained throughout on ticagrelorhad the highest bleeding (1.96%).
ABBREVIATIONS:BARC, Blood Academic Research Consortium; EMR, electronic medical record; GP, glycoprotein; PCI, percutaneous coronary intervention.
Soueid AE, Kassas I, Rade J, Kakouros N. Evaluation of a real-world in-hospital antiplatelet-switching strategy following coronary interventions: The SWITCH Study. J Invasive Cardiol. 2021;33(4):E263–E268. PMID: 33794478.