Prasugrel matches ticagrelor with less bleeding after stenting

A treatment decision usually happens beside a hospital bed, one patient at a time. In Sweden, seven health-care regions changed that decision across entire populations: they switched their default drug after coronary stenting from ticagrelor to prasugrel at randomly assigned times. The resulting trial included 17,095 adults with acute coronary syndromes, and the first result is clear: prasugrel offered similar protection against major cardiovascular events after one year, with less major bleeding.

The endpoint combined death from any cause, myocardial infarction and stroke. It occurred in 11.1% of patients under the prasugrel policy and 11.8% under the ticagrelor policy, a difference that was not statistically conclusive. The individual components did not differ either. Major bleeding, however, occurred in 4.2% under prasugrel and 4.4% under ticagrelor; the trial reported this difference as statistically significant.

The design matters. Rather than assigning each patient individually, SWITCH SWEDEHEART randomized regions and used the established SWEDEHEART registry. That made it possible to include groups often left out of conventional trials, including elderly patients, people with a previous stroke and those with an indication for oral anticoagulation. Prasugrel was recommended at 10 mg once daily, reduced to 5 mg for patients aged 75 or older or weighing less than 60 kg; ticagrelor was recommended at 90 mg twice daily.

And so, concretely? For hospitals treating a broad population after PCI, prasugrel now has randomized, registry-based evidence supporting comparable one-year cardiovascular protection and a lower rate of major bleeding than a ticagrelor policy. That could influence default prescribing for clinicians and reduce uncertainty for patients, while health systems may also weigh the lower cost cited by the investigators. The 2023 European Society of Cardiology guidelines already place prasugrel ahead of ticagrelor as a consideration for this group.

The limits are part of the result. This was a policy-level comparison, not a direct randomization of every individual, and the bleeding difference was modest in absolute terms. The figures were presented at ESC Congress 2026 and published in the New England Journal of Medicine; the trial shows what happened under regional treatment policies in everyday care, not that every patient should receive the same drug.