Cole, A

Abstract Background Individuals with cancer are at increased risk of acute myocardial infarction (AMI), yet selecting optimal dual antiplatelet therapy (DAPT) remains challenging due to competing risks of thrombosis and bleeding. Aims This study examined patterns of DAPT use and associated outcomes following AMI in patients with active cancer. Methods Using the TriNetX global registry, we identified adults hospitalised with AMI and active cancer between January 2015 and January 2020. Outcomes assessed included all-cause mortality, major bleeding, and AMI readmission up to five years. Results Among 20,000 patients, 78.6% received clopidogrel, 17.6% ticagrelor, and 3.9% prasugrel as their second antiplatelet agent. Those prescribed clopidogrel were older (72.6 ± 10.5 years) than those on ticagrelor (69.8 ± 10.9) or prasugrel (67.2 ± 10.4; p < 0.001) and had a higher prevalence of cardiovascular comorbidities, including hypercholesterolemia (clopidogrel: 62% vs ticagrelor: 53% and prasugrel: 58%) and hypertension (clopidogrel: 77% vs ticagrelor: 69% and prasugrel: 72%). After adjustment for baseline characteristics, five-year mortality was lower with prasugrel and ticagrelor compared with clopidogrel (clopidogrel 29.1%, prasugrel 23.6%, p = 0.03; ticagrelor 30.1%, prasugrel 23.6%, p = 0.01). No significant differences were observed in major bleeding rates between treatment groups. Conclusion Clopidogrel remains the most frequently used second antiplatelet in patients with active cancer presenting with AMI. However, ticagrelor and prasugrel were associated with improved long-term survival without increasing bleeding risk. These findings suggest the need for further evaluation of more potent P2Y12 inhibitors in this high-risk population.