Losciale C. et al. (Eur Heart J Cardiovasc Pharmacother. 2026. doi: 10.1093/ehjcvp/pvag027) analyzed data from the Swedish national SWEDEHEART registry to evaluate changes in discharge antithrombotic therapies and associations with 1-year clinical outcomes, in a cohort of over 71,000 patients with acute myocardial infarction (AMI) and concomitant atrial fibrillation (AF) enrolled between 2000 and 2021. The study documented a progressive increase in oral anticoagulant use, rising from 21% in 2000 to 75% in 2020, driven primarily by the adoption of direct oral anticoagulants (DOACs) following their introduction in 2011. With regards to antiplatelet agents, dual antithrombotic therapy consisting of a DOAC plus a single antiplatelet agent became the predominant strategy. This treatment adjustment likely explains why, after an initial increase, the risk of major bleeding subsequently declined, reflecting the replacement of warfarin with DOACs and the progressive deescalation of the triple antithrobotic therapy.
In parallel, the authors observed a substantial reduction in the incidence of ischemic stroke or systemic embolism (from 6.0% to 2.1%) and CV mortality (from 19.8% to 10.5%).
Although observational, this study underscores the importance of a correct antithrombotic strategy.
These findings should be regarded in light of the recent EPIDAURUS trial (Nat Med. 2026 Aug 29. doi: 10.1038/s41591-026-04629-7.), which further highlights the delicate balance between ischemic and bleeding risk in patients with AF and acute coronary syndromes. While dual antithrombotic therapy has become the preferred strategy, intensifying platelet inhibition with prasugrel or ticagrelor increased bleeding without a clear ischemic benefit in that trial. Together, these data reinforce the importance of carefully balancing antithrombotic efficacy and safety in this high-risk population.
