SWITCH SWEDEHEARTAcute Coronary SyndromesNew England Journal of Medicine
Prasugrel versus Ticagrelor in Acute Coronary Syndrome After Percutaneous Coronary Intervention
Prasugrel versus Ticagrelor in Acute Coronary Syndromes
View Full PaperWhy 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?
Population
17,095 ACS patients after PCI in Sweden (mean age 69.8, 27.8% female)
Comparison
Default prasugrel policy vs default ticagrelor policy
Design
Registry-based open-label stepped-wedge cluster-randomized trial
Follow-up
1 year
Key result
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).
Authors
Discussion
Key questions
Author asks
Elmir Ömerovic12d ago
Cardiology · Sahlgrenska University Hospital
What should clinicians watch for when these results land?
SWITCH SWEDEHEART co-authorMember takes
Where experts stand
Experts read SWITCH-SWEDEHEART as a well-designed pragmatic trial that found no significant difference between prasugrel and ticagrelor policies after PCI for ACS, though some see the bleeding signal and point estimates as enough to keep prasugrel as first choice.
Most experts agree the trial showed no clear winner between default prasugrel and default ticagrelor policies for preventing death, MI, or stroke. A key point of discussion is that this compared institutional policies rather than individual drug assignments, with incomplete crossover in each arm. The open question is whether the modest bleeding advantage for prasugrel, combined with prior evidence, should move guidelines to formally prefer it.
Main debate
Does SWITCH-SWEDEHEART support prasugrel as first choice, or leave the question open?
Prasugrel should remain first choice1
The point estimate favored prasugrel and the bleeding benefit was significant, reinforcing its position as the default.vs
No reason to change current practice either way1
The primary endpoint was not significantly different, so neither drug can be declared superior.Not placed5 reporting, watching, or context only
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
Experts question whether the incomplete uptake of the policy-assigned drug (only about 61% in the prasugrel group) diluted the treatment effect and what a true per-protocol comparison would show. It remains unclear whether guidelines will move to formally prefer one agent or continue to list both as equivalent options. The relevance of the significant bleeding reduction with the prasugrel policy, when the primary ischemic endpoint was neutral, also needs further interpretation.
Key expert perspectives
Davide CapodannoInterventional / Structural Cardiology · University of CataniaEndpoint critiqueAug 30This compared policies, not drugs, and incomplete crossover complicates interpretation
Capodanno highlights that SWITCH-SWEDEHEART is a comparison between policies, not between drugs. The policy-recommended agent was dispensed to 75.8% under ticagrelor and only 60.6% under prasugrel, raising questions about what drove the observed differences.
Distilled from their postX post
AEAlfredo E RodriguezInterventional cardiologist, cardiovascular researcherPractice takeSep 9
Findings should not change practice: prasugrel should remain the first indication after ACS with stenting
Rodriguez notes the editorial's discussion of limitations in the randomization scheme. He argues the findings should not change current practice with DAPT in ACS undergoing DES implantation and that prasugrel should remain the first-line choice.
Distilled from their postOriginal post
The trial addressed a long-unanswered question on prasugrel versus ticagrelor
Damluji provides a structured walkthrough of the trial, noting that the choice between prasugrel and ticagrelor has remained an unanswered question and highlighting the registry-based stepped-wedge cluster-randomized design.
Overview
Neither default policy reduces ischemic events more than the other in ACS after PCI; confirms comparable real-world effectiveness and safety.
Key Points
- To assess whether a default treatment policy of prasugrel is superior to ticagrelor in reducing ischemic events among patients undergoing percutaneous coronary intervention for acute coronary syndromes.
- Conducted an open-label, stepped-wedge, cluster-randomized registry trial in Sweden (NCT05183178) across 7 regions transitioning from ticagrelor to prasugrel over four 9-month periods (2021–2024).
- Enrolled 17,095 adults undergoing PCI for acute coronary syndromes (9,444 default ticagrelor; 7,651 default prasugrel) with 1-year registry-based follow-up.
- Evaluated a primary composite endpoint of all-cause mortality, myocardial infarction, or stroke using cluster- and calendar-adjusted mixed models.
- At 1 year, the primary composite endpoint occurred in 11.1% of patients in the prasugrel group versus 11.8% in the ticagrelor group (adjusted OR 0.90; 95% CI, 0.77 to 1.06).
- Major bleeding events occurred in 4.2% of patients under the prasugrel policy compared with 4.4% under the ticagrelor policy (adjusted OR 0.80; 95% CI, 0.64 to 0.99).
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
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.
Main Result
Odds Ratio: 0.9 (95% CI 0.77–1.06)
Absolute Event Rate: 11.1% vs 11.8%
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).