View all ESC 2026 trials
Prasugrel versus Ticagrelor in Acute Coronary Syndromes
Key result
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
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?
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
Authors
Discussion
Key questions
Author asks
Jonas Rahman38d ago
What should clinicians watch for when these results land?
SWITCH SWEDEHEART co-authorNo takes yet. Share an insight, caveat, or question.
Where experts stand
Experts read SWITCH SWEDEHEART as a well-executed pragmatic trial that found no significant advantage for a default prasugrel policy over ticagrelor after PCI for ACS, with most reaction focused on what the policy-level design can and cannot tell us about individual drug choice.
Most experts treat this as a neutral result: switching an entire region's default antiplatelet from ticagrelor to prasugrel did not meaningfully reduce death, MI, or stroke. Some highlight a bleeding signal favoring prasugrel, while others question whether the trial's policy-level comparison, with incomplete crossover, can guide individual prescribing. The live question is whether guidelines should now treat the two drugs as interchangeable or whether the modest bleeding difference and design limitations warrant further study.
Agreement
Experts broadly agree that the primary endpoint showed no significant difference between a default prasugrel policy and a default ticagrelor policy for reducing death, MI, or stroke after PCI for ACS.
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 modest bleeding reduction favoring the prasugrel policy should influence guideline recommendations, given the incomplete crossover in both arms. It remains open whether a head-to-head individual-level randomized trial would yield a different answer than this policy-level comparison. Experts also ask whether specific patient subgroups might still benefit from one drug over the other.
Key expert perspectives
Davide CapodannoInterventional / Structural Cardiology · University of CataniaEndpoint critiqueAug 30This compared policies, not drugs, and incomplete crossover complicates interpretation
Capodanno stresses that SWITCH-SWEDEHEART is a comparison between policies, not between drugs. He notes that the policy-recommended agent was dispensed to only 60.6% of patients in the prasugrel-policy group versus 75.8% in the ticagrelor-policy group, raising questions about why the prasugrel-policy group still experienced less bleeding.
Distilled from their postX post
The choice between prasugrel and ticagrelor has remained unanswered, and this trial tested that question at scale
Damluji walks through the trial's stepped-wedge cluster-randomized design and frames it as addressing a long-standing open question in dual antiplatelet therapy. He highlights the registry-based pragmatic approach covering roughly half of Sweden's population.
No significant difference in death, MI, or stroke at 1 year between prasugrel and ticagrelor policies
Asher summarizes the primary endpoint: death, MI, or stroke at 1 year was 11.1% with prasugrel versus 11.8% with ticagrelor, adjusted OR 0.90 (95% CI 0.77-1.06), confirming no statistically significant difference.
Distilled from their postX post
Implication
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
Main Result
Odds Ratio: 0.9 (95% CI 0.77–1.06)
Absolute Event Rate: 11.1% vs 11.8%
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.
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).