Antiplatelet therapy is paramount to reduce the risk of coronary stent thrombosis after percutaneous coronary intervention (PCI). Newer agents are reliable and have a fast onset of action, but have significantly higher cost, leading to compliance concerns. We adopted and evaluated an acute agent-switching strategy, using prasugrel or ticagrelor for rapid and reliable periprocedural antiplatelet action, followed by a switch to generic clopidogrel.
This large, single-center study included all patients who underwent PCI between January 1, 2013 and December 31, 2016. Study endpoints were 30- day mortality and bleeding events.
A total of 5007 patients met inclusion criteria. Average age was 63.5 ± 12.5 years. Prior to PCI, 54.8% of patients were preloaded with ticagrelor, 8.5% with prasugrel, and 36.7% with clopidogreI. The majority of patients (93%) loaded with ticagrelor and more than half (58%) of those loaded with prasugrel were subsequently switched prior to hospital discharge to clopidogrel for long-term therapy. Patients pretreated with ticagrelor or prasugrel and switched to clopidogrel had overall lowest bleeding rates (0.9% and 0.8%, respectively). The highest rates of bleeding were noted in patients maintained on ticagrelor or clopidogrel throughout (2.5% and 1.7%, respectively). After accounting for additional periprocedural use of intravenous glycoprotein IIb/IIIa inhibitors, the lowest bleeding rates were observed in patients loaded with ticagrelor and switched to clopidogrel (0.75%), with the highest bleeding observed in patients maintained on ticagrelor throughout. There were no events of acute stent thrombosis.
A strategy of using newer, fast-acting, and reliable antiplatelet agents prior to PCI and acutely switching to long-term clopidogrel therapy appears safe and efficacious. Although the superiority of the newer antiplatelet agents for long-term post-PCI dual-antiplatelet therapy in a trial setting is well established, the impact of increased adherence to lower-cost clopidogrel therapy in the real-world setting merits further consideration.