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Rafael Gomes: Can Prasugrel Replace Ticagrelor in ACS Treatment?
Rafael Gomes/LinkedIn
Aug 31, 2026, 13:36

Rafael Gomes: Can Prasugrel Replace Ticagrelor in ACS Treatment?

Rafael Gomes, Cardiologist, Echocardiographer, Ergometrist at Real Hospital Português, shared a post on LinkedIn about a recent article by Elmir Omerovic et al., published in NEJM, adding:

“European Society of Cardiology Munich 2026 – Switch-Swedeheart: prasugrel or ticagrelor after ACS PCI?

The Switch-Swedeheart trial, presented by Prof. Dr. Elmir Omerovic, evaluated a pragmatic real-world question: should prasugrel replace ticagrelor as the default P2Y12 strategy in ACS patients undergoing PCI?

Rather than randomizing individual patients, Swedish regions were randomized to switch their default policy from ticagrelor to prasugrel.

  • 17,095 ACS patients undergoing PCI.
  • Mean age approximately 70 years.
  • 37% equal to or more than 75 years.
  • Previous stroke and oral anticoagulation were included.
  • Complete 1-year follow-up.

Primary endpoint: death, MI or stroke at 1 year

Ticagrelor policy: 11.8%

Prasugrel policy: 11.1%

Adjusted OR 0.90; 95% CI 0.77-1.06; P is equal to 0.22

A prasugrel-default strategy did not significantly reduce ischemic events compared with ticagrelor.

Individual outcomes were also similar, including death, MI, stroke and stent thrombosis.

Major bleeding was lower with the prasugrel policy by registry-based ICD-10 definitions, but these analyses were not adjusted for multiplicity and should be interpreted cautiously.

A crucial point highlighted by Prof Dr. Roxana Mehran, who discussed the trial, is that this was a comparison of policies, not pure pharmacological equivalence.

Only 75.8% of patients in the ticagrelor-policy group actually received ticagrelor, and only 60.6% in the prasugrel-policy group received prasugrel.

Her key message:

‘A neutral policy comparison is not a demonstration of pharmacological equivalence.’

This is important when interpreting the trial alongside ISAR-React 5, which remains the main basis for the ESC preference for prasugrel in ACS patients proceeding to PCI.

Take-home message

Switch-Swedeheart does not show that prasugrel and ticagrelor are equivalent.

It shows that, in broad real-world ACS care, making prasugrel the default strategy did not significantly improve 1-year ischemic outcomes compared with ticagrelor.

The study refines, rather than overturns, ISAR-React 5 – and reinforces the importance of individualized P2Y12 selection.”

Title: Prasugrel versus Ticagrelor in Acute Coronary Syndromes

Authors: Elmir Omerovic, Sasha Koul, Jonas Andersson, Johan Pontén, Fredrik Björklund, Robert Kastberg, Mila Sun, Charlotta Ljungman, Ole Fröbert, Kristian Bolin, Kristofer Skoglund, Carl-David Dolata, Mats Birgander, Helena Wikström, Truls Råmunddal, Oskar Angerås, Petur Petursson, David Erlinge, Björn Redfors

Rafael Gomes

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ACS Anticoagulation Björn Redfors Carl-David Dolata Charlotta Ljungman David Erlinge Elmir Omerovic ESC 2026 Fredrik Björklund Health Helena Wikström Hematology Hemostasis Hemostasis News Hemostasis Today International Society on Thrombosis and Haemostasis Johan Pontén Jonas Andersson Kristian Bolin Kristofer Skoglund Mats Birgander Medicine MI Mila Sun Ole Fröbert Oskar Angerås PCI Petur Petursson Rafael Gomes Robert Kastberg Roxana Mehran Sasha Koul stroke thrombosis Truls Råmunddal
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