The SWITCH study: antiplatelet-switching strategy after coronary interventions

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.

MAT-BH-2300015/v1/Jan2023