This compared policies, not drugs, and adherence to prasugrel was only about 61%
X post ↗What happened
Default prasugrel shows no benefit over default ticagrelor for primary events at 1 year.
- OR 0.90
- 95% CI 0.77 to 1.06
- n=17,095
- 11.1% vs 11.8% at 1 year
Does this change practice?
Where experts agree
Multiple clinicians agree that a default prasugrel policy did not significantly reduce death, MI, or stroke compared with a default ticagrelor policy at one year.
What this trial adds
Experts broadly read SWITCH SWEDEHEART as a null result for the primary ischemic endpoint, with most noting that a default prasugrel policy did not significantly reduce death, MI, or stroke versus ticagrelor, though some highlight the bleeding signal favoring prasugrel as clinically relevant.
Published field read
Most experts describe this as a neutral comparison: switching a hospital's default from ticagrelor to prasugrel did not meaningfully lower ischemic events. A few voices emphasize the lower major bleeding with prasugrel as a potential practice consideration. The open question is whether the bleeding finding and the pragmatic policy design are enough to shift guidelines toward prasugrel as the preferred agent after PCI for acute coronary syndromes.
Still open
Questions raised in published commentaryWhether the lower major bleeding rate with prasugrel is sufficient to favor it over ticagrelor in guidelines, given that the primary ischemic endpoint was not significantly different.
How much the incomplete uptake of the policy-assigned drug (about 61% in the prasugrel group) diluted any true drug-level difference.
Whether subgroups such as older patients or those with prior stroke may respond differently to each agent.
Context from published commentary. Source summaries are not a new guideline recommendation.
Who says what
Author asks
Elmir Ömerovic63d ago
Cardiology · Sahlgrenska University Hospital
What should clinicians watch for when these results land?
SWITCH SWEDEHEART co-author
The trial addresses an unanswered question on prasugrel vs ticagrelor using a pragmatic design
X post ↗
Default prasugrel did not significantly reduce death, MI, or stroke versus ticagrelor at 1 year
X post ↗Show 8 more perspectivesShow fewer perspectives
No significant difference in death, MI, or stroke between the two default policies
X post ↗
C. Michael GibsonResults readoutInterventional / Structural Cardiology · Beth Israel Deaconess Medical Center
Switching from ticagrelor to prasugrel did not lower death, MI, or stroke at 1 year
X post ↗Björn Redfors
ContextProfessor and senior consultant, Sahlgrenska University HospitalThe legal framework behind the trial creates clarity for future pragmatic research
Original post ↗
Summarized the trial as showing that ischemic event risk was not lower with a default prasugrel versus ticagrelor policy.
X post ↗MD Kemal Karaagac@kemalkaraaa1
“When prasugrel is considered the default antiplatelet choice for patients with ACS who undergo PCI, major bleeding events occur than if the default had been ticagrelor. SWITCH-SWEDEHEART study. Moreover, this benefit does NOT come at the expense ofischemic events.”
X ↗Mamas A. Mamas
@mmamas1973“My @TCTMD Beyond the Data: SWITCH-SWEDEHEART video with @elmir1omerovic and jurrien ten Berg. Does a policy change to prasugrel impact on clinical outcomes? Should this trial change practice/guidelines?”
X ↗Intensive Care Unit Algorithms Lab
@icualgorithmlab“Prasugrel or ticagrelor after PCI for ACS? SWITCH SWEDEHEART tested this question in 17,095 consecutive real-world patients using a registry-based, stepped-wedge cluster-randomized design. Seven Swedish regions switched their default policy from: Ticagrelor 90 mg twice”
X ↗Helena Carrick
Gothia Forum“We could not have done it without each other. The researchers contributed deep medical understanding; we were able to translate that into legal arguments the court could assess. This was a true team effort.”
News Coverage ↗What should the author answer first?
Upvote a question you would like answered, or open it to join the discussion.
Full evidence
Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Full evidence
Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Why the trial?
Ticagrelor's twice-daily dosing, dyspnoea and bleeding drive frequent discontinuation after acute coronary syndrome. Whether routinely switching from ticagrelor to once-daily prasugrel improves outcomes had not been tested at scale in a randomised setting.
Does a default prasugrel policy reduce ischemic events compared to a default ticagrelor policy in adults undergoing percutaneous coronary intervention for acute coronary syndrome?
View moreView less
Evidence details
What drove the result?
| Outcome | Prasugrel | Ticagrelor |
|---|---|---|
| Death, MI, or stroke at 1 year | 11.1% | 11.8% |
| Adjusted OR 0.90 (95% CI 0.77-1.06) - no significant difference between policies | ||
Limitations & tradeoffs
Safety
Major bleeding 4.2% vs 4.4%; adjusted OR 0.80 (95% CI 0.64-0.99).
Design limitations
policy-level cluster comparison (regions switched defaults) rather than individual-patient randomization, open-label with outcomes ascertained from national registries.
Statistical certainty
estimates required adjustment for cluster and calendar time in a stepped-wedge design.
Structured PICO
Does a default prasugrel policy reduce ischemic events compared to a default ticagrelor policy in adults undergoing percutaneous coronary intervention for acute coronary syndrome?
P
Population
17,095 adults who had undergone percutaneous coronary intervention for an acute coronary syndrome, followed for 1 year.
I
Intervention
Default prasugrel policy
C
Comparator
Default ticagrelor policy
O
Outcome
Primary end-point event (ischemic events) at 1 yearcomposite
Main Result
Odds Ratio: 0.9 (95% CI 0.77–1.06)
Absolute Event Rate: 11.1% vs 11.8%
Discussion
1 takeMember takes
Lars WallentinSep 9
Great study pioneering to use of cluster randomization in registries to test different treatment strategies in real life. Very useful cost-effective model when implementing novel treatment strategies in the real life setting. The comparison of the strategies "prasugrel first choice" vs "ticagrelor first choice" turned out neutral on efficacy - safety difficult to evaluate in this setting. Good to have two similar alternatives to tailor to different patients and settings.
Expert reaction
What experts said about SWITCH SWEDEHEART
NEJM · ESC Congress 2026
Expert labels are toward SWITCH SWEDEHEART's result, from named public quotes (n=4). As of Aug 30, 2026.
Where experts stand
Experts broadly read SWITCH SWEDEHEART as a null result for the primary ischemic endpoint, with most noting that a default prasugrel policy did not significantly reduce death, MI, or stroke versus ticagrelor, though some highlight the bleeding signal favoring prasugrel as clinically relevant.
Most experts describe this as a neutral comparison: switching a hospital's default from ticagrelor to prasugrel did not meaningfully lower ischemic events. A few voices emphasize the lower major bleeding with prasugrel as a potential practice consideration. The open question is whether the bleeding finding and the pragmatic policy design are enough to shift guidelines toward prasugrel as the preferred agent after PCI for acute coronary syndromes.
Agreement
Multiple clinicians agree that a default prasugrel policy did not significantly reduce death, MI, or stroke compared with a default ticagrelor policy at one year.
3 clinicians say this directly
What they’re arguing about
supportiveneutralcautiouscritical
Counts are expert takes we classified by axis. Tap a row to see the takes behind its count.
Still unclear
Whether the lower major bleeding rate with prasugrel is sufficient to favor it over ticagrelor in guidelines, given that the primary ischemic endpoint was not significantly different. How much the incomplete uptake of the policy-assigned drug (about 61% in the prasugrel group) diluted any true drug-level difference. Whether subgroups such as older patients or those with prior stroke may respond differently to each agent.
Key expert perspectives
EOElmir OmerovicProfessor and senior consultant, Sahlgrenska University HospitalContextBefore results
This project shows treatments can be evaluated in the real world efficiently
Omerovic, the trial's principal investigator, argues the study demonstrates that real-world treatment comparisons can be combined with high-quality patient care and efficient use of resources.
Distilled from their postOriginal post
Davide CapodannoInterventional / Structural Cardiology · University of CataniaEndpoint critiqueAug 30This compared policies, not drugs, and adherence to prasugrel was only about 61%
Capodanno emphasizes that SWITCH-SWEDEHEART compares treatment policies rather than drugs head-to-head. He notes the policy-recommended agent was dispensed to 75.8% in the ticagrelor group but only 60.6% in the prasugrel group, raising the question of why bleeding was still lower in the prasugrel arm despite incomplete uptake.
Distilled from their postX post
The trial addresses an unanswered question on prasugrel vs ticagrelor using a pragmatic design
Damluji walks through the trial's rationale, noting that the choice between prasugrel and ticagrelor after ACS has remained unresolved. He highlights the registry-based, stepped-wedge, cluster-randomized design across seven Swedish regions.
Implication
In patients undergoing PCI for ACS, a default prasugrel policy did not significantly reduce ischemic events at 1 year compared to a default ticagrelor policy.
Abstract
Background Whether prasugrel or ticagrelor should be the preferred P2Y12 inhibitor for patients with an acute coronary syndrome is uncertain. Methods We conducted a registry-based, open-label, stepped-wedge, cluster-randomized trial in Sweden involving adults who had undergone percutaneous coronary intervention for an acute coronary syndrome. Seven regions, grouped into three clusters, switched from ticagrelor to prasugrel as the default P2Y12 inhibitor in a randomized sequence across four 9-month periods between 2021 and 2024. The primary end point was a composite of death from any cause, fatal or nonfatal myocardial infarction, or fatal or nonfatal stroke through 1 year, as ascertained from national registries. In the intention-to-treat analysis, a mixed model adjusted for cluster and calendar time was used to obtain a policy-level estimate. Results A total of 17,095 patients were enrolled; 9444 received care under the default ticagrelor policy, and 7651 received care under the default prasugrel policy. The mean (±SD) age of the patients was 69.8±11.5 years, and 36.8% were at least 75 years old; 27.8% of the patients were female. A total of 39.4% presented with ST-segment elevation myocardial infarction (STEMI), 43.7% with non-STEMI, and 16.8% with unstable angina. At 1 year, a primary end-point event had occurred in 11.8% of the patients in the ticagrelor-policy group and in 11.1% of those in the prasugrel-policy group (adjusted odds ratio [prasugrel vs. ticagrelor], 0.90; 95% confidence interval [CI], 0.77 to 1.06), and major bleeding had occurred in 4.4% and 4.2%, respectively (adjusted odds ratio, 0.80; 95% CI, 0.64 to 0.99). Conclusions In an unselected population of patients with an acute coronary syndrome who had undergone percutaneous coronary intervention, the risk of ischemic events was not lower with a default prasugrel policy than with a default ticagrelor policy. (Funded by Region Västra Götaland; SWITCH-SWEDEHEART ClinicalTrials.gov number, NCT05183178.)
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Ömerovic et al. (2026) conducted an RCT in Acute coronary syndrome (n=17,095). Prasugrel vs. Ticagrelor was evaluated on Composite of death from any cause, fatal or nonfatal myocardial infarction, or fatal or nonfatal stroke (OR 0.90, 95% CI 0.77 to 1.06). In patients with acute coronary syndrome undergoing PCI, a default prasugrel policy did not lower the risk of ischemic events compared with a default ticagrelor policy (OR 0.90; 95% CI 0.77-1.06).