Original title: In-hospital switching of oral P2Y12 inhibitor treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention: Prevalence, predictors and short-term outcome. Reference: Dimitrios Alexopoulos et al. Am Heart J 2014;167:68-76.e2.

Given the availability of 3 Oral P2Y12 receptor inhibitors (clopidogrel, prasugrel, and ticagrelor) with different safety and efficacy profiles, the change from one to another during the hospitalization of a patient admitted with acute coronary syndrome has become a frequent practice but little clinical evidence. The present study in the context of GRAPE registry (Greek Antiplatelet Registry) analyzed 1794 patients experiencing acute coronary syndrome who received angioplasty in order to investigate the prevalence, predictive factors, and short-term outcomes switching anti-aggregation. The initial indication of any changes and or antiplatelet aggregating was at the discretion of the treating physicians. Of the total, 664 patients received only clopidogrel (37%), prasugrel only 146 (8.1 %) and ticagrelor only 343 (19.1 %). Furthermore, the change from one to another occurred in 636 patients (35.5 %). Among those, the most common change was from clopidogrel to either of the two newer agents (575 patients 90.4 %) while the change of prasugrel or ticagrelor to clopidogrel or to switch between prasugrel and ticagrelor was uncommon (5.3 % and 4.3 % respectively).

The initial presentation in the center without angioplasty capabilities and in-hospital use of bivalirudin were predictors to change clopidogrel to some of the newer drugs, while age ≥ 75 was a predictor of staying with clopidogrel. No significant differences were observed when comparing those who switched from clopidogrel to prasugrel or ticagrelor versus those receiving prasugrel or ticagrelor from the beginning in terms of MACE (death, MI, stent thrombosis, urgent revascularization, or stroke) and bleeding criteria by BARC (Bleeding Academic Research Consortium) after matching groups with propensity score. Unlike the above, comparing those who switched from clopidogrel to prasugrel or ticagrelor versus those who always continued clopidogrel; increased bleeding was seen in those who changed but less MACE.

Conclusion

Anti -platelet switching between patients admitted experiencing acute coronary syndrome is a common fact that is affected by both clinical and regional factors. Clopidogrel change to a newer agent could be associated with increased bleeding. 

Editorial comment

For the PLATO study having received clopidogrel was not an exclusion criterion, that is why 46 % of patients randomized to ticagrelor had this background, something similar was seen in the TRILOGY ACS with prasugrel. No differences were observed in any of the two studies according to previous history of clopidogrel. Another question is whether loading dose should be administered to make the change. For this registry, 54.7 % of those switched from ticagrelor received load versus 32.5 % of those switched to prasugrel.

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