Switching Antiplatelet Therapy-5 - SWAP-5

Contribution To Literature:

The SWAP-5 trial showed that among patients receiving a loading dose of ticagrelor, platelet reactivity with cangrelor was noninferior to placebo 2 hours after discontinuation of drug infusion.


The goal of the trial was to assess the impact of cangrelor among patients pretreated with ticagrelor.

Study Design

Eligible patients were enrolled in a double-blinded 1:1 fashion to either receive ticagrelor loading dose followed after 1 hour by cangrelor bolus and infusion (n = 20) or ticagrelor loading dose followed after 1 hour by placebo bolus and infusion. Ticagrelor was administered as a 180 mg loading dose and cangrelor as a 30 μg/kg bolus followed by 4 μg/kg/min infusion. Cangrelor/placebo infusion was continued for a duration of 2 hours. After completing the first phase of the study, patients underwent a 1–4-week wash-out period and then crossed over to the alternative treatment in the second phase (i.e., patients assigned to treatment with cangrelor in the first phase were assigned to placebo in the second phase and vice-versa).

  • Total number of enrollees: 20
  • Duration of follow-up: 30 days
  • Mean patient age: 68.4 years
  • Percentage female: 55%
  • Black: 50%

Inclusion criteria:

  • Patients ≥18 years of age
  • Stable coronary artery disease (CAD) on therapy
  • On low-dose aspirin (81 mg/qd) for ≥1 month

Exclusion criteria:

  • Any active bleeding
  • High risk for bleeding
  • Use of an oral P2Y12 receptor inhibitor or an oral anticoagulant in the prior 30 days
  • End-stage renal disease on hemodialysis
  • Known allergies to ticagrelor or cangrelor

Other salient features/characteristics:

  • Diabetes mellitus: 90%
  • Prior percutaneous coronary intervention: 65%

Principal Findings:

The primary outcome, VerifyNow P2Y12 Reaction Units (PRU) 2 hours after infusion, for cangrelor vs. placebo, was: 16.9 vs. 12.6 (p = 0.78).

Secondary outcomes:

  • Adding cangrelor was associated with a significant reduction in PRU at 30 minutes (p = 0.001) and 1 hour (p = 0.005) after bolus administration as compared to placebo
  • Tmax for ticagrelor in cangrelor vs. placebo: 2 vs. 2 hours (p = 0.16)


The results of this trial indicate that among patients who have been pretreated 1 hour prior with a 180 mg loading dose of ticagrelor, cangrelor further enhances P2Y12 inhibitory effects up to 1 hour after initiation of bolus and infusion compared with placebo. In addition, platelet reactivity among cangrelor-treated patients was noninferior to that observed among placebo-treated patients at 2 hours after discontinuation of drug infusion, ruling out a drug-drug interaction.


Franchi F, Ortega-Paz L, Rollini F, et al. Cangrelor in Patients With Coronary Artery Disease Pre-treated With Ticagrelor: The Switching Antiplatelet (SWAP)-5 Study. JACC Cardiovasc Interv 2022;Oct 31:[Epub ahead of print].

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease

Keywords: AHA Annual Scientific Sessions, AHA22, Aspirin, Coronary Artery Disease, Diabetes Mellitus, Drug Interactions, Percutaneous Coronary Intervention, Pharmacokinetics, Platelet Aggregation Inhibitors, Secondary Prevention, Ticagrelor

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