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 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.

MAT-BH-2300015/v1/Jan2023