- Design
- Registry-based, open-label, stepped-wedge, cluster-randomised trial
- Population
- 17,095 patients in Sweden after PCI for acute coronary syndrome (mean age 70)
- Primary outcome
- Death, MI or stroke at 1 year
- Effect
- 11.1% vs 11.8%; adjusted OR 0.90 (95% CI 0.77–1.06)
SWITCH-SWEDEHEART tested a policy question with registry data. Seven Swedish regions, in three clusters, switched the default P2Y12 inhibitor after PCI for acute coronary syndrome from ticagrelor to prasugrel in a randomised sequence across four nine-month periods between 2021 and 2024. The trial included 17,095 unselected patients: mean age 70, 37% aged 75 or more, 39% with STEMI.
At one year, death, MI or stroke occurred in 11.1% under the prasugrel policy and 11.8% under ticagrelor (adjusted OR 0.90, 95% CI 0.77 to 1.06). Major bleeding was 4.2% vs 4.4% (adjusted OR 0.80, 0.64 to 0.99).
The earlier ISAR-REACT 5 trial had favoured prasugrel, and some guidelines followed it. In a real-world population with many older patients, prasugrel was not better for ischaemic events. The bleeding result was marginal. Either drug is reasonable; weigh guideline advice alongside dosing, cost, side effects such as ticagrelor dyspnoea, and patient factors.
- Prasugrel and ticagrelor gave similar ischaemic outcomes at one year after PCI for acute coronary syndrome.
- Avoid prasugrel after any prior stroke or TIA.
- In patients aged 75 or more or weighing under 60 kg, prasugrel needs the 5 mg maintenance dose if used at all.
- Ticagrelor causes breathlessness in some patients; if it is persistent and troublesome, and other causes are excluded, consider switching rather than stopping antiplatelet therapy.
- In India, generic prasugrel and ticagrelor are both available; cost and twice-daily dosing may decide adherence.
Why it matters
It questions the guideline preference for prasugrel that rested on a single earlier trial.
Don't overread it
This is a comparison of default hospital policies in an open-label design, not a blinded head-to-head drug trial.
The statistics, in plain English
The odds ratio for ischaemic events (0.90) has a 95% CI from 0.77 to 1.06, which crosses 1.0, so no difference is shown. The bleeding CI (0.64 to 0.99) only just excludes 1.0, a weak signal. A stepped-wedge design compares policies over time rather than individual patients, which reflects practice but is less tightly controlled than a conventional trial.
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