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Real-world in-hospital antiplatelet-switching strategy after coronary interventions: The Switch study

Key takeaway

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.

Study design

  • 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

Key results

  • 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
  • Bleeding events:
    • 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%)

Limitations

  • 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%).

Abbreviations

BARC, Blood Academic Research Consortium; EMR, electronic medical record; GP, glycoprotein; PCI, percutaneous coronary intervention.

Reference

  1. 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.

Disclaimer: The images depicted here are fictitious and meant for illustrative purpose only. Any resemblance to any person, living or dead is purely coincidental.

MAT-IN-2301694-1.0-07/2023