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 with ticagrelor
58% patients initially loaded with prasugrel
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
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 differed across treatment arms)
- Rationale for selection and switching between P2Y12 inhibitors was at the treating physician’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 to ticagrelor; 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 and switched to clopidogrel had the lowest BARC 3a bleeding rates (0.75%) and patients maintained throughout on ticagrelor had the highest bleeding (1.96%).
BARC, Blood Academic Research Consortium; EMR, electronic medical record; GP, glycoprotein;
PCI, percutaneous coronary intervention.
Disclaimer: The images depicted here are fictitious and meant for illustrative purpose only. Any resemblance to any person, living or dead is purely coincidental.
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.