Utilization and Outcomes of Dual Antiplatelet Therapy in Patients With Active Cancer Presenting With Acute Myocardial Infarction: A Global Registry Study

Individuals with cancer have an elevated risk of mortality following acute myocardial infarction (AMI), yet selecting optimal dual antiplatelet therapy (DAPT) is challenging due to competing risks of thrombosis and bleeding. We evaluated patterns of DAPT use and associated outcomes in this population. Using the TriNetX global registry, we identified adults hospitalized with AMI and active cancer who were prescribed DAPT between January 2015 and January 2020. The primary outcome was all-cause mortality at 1 and 5 years. Secondary outcomes were major bleeding events and AMI readmission up to 5 years. Adjusted hazard ratios (aHRs) were estimated using Cox proportional hazards models. Clopidogrel was the most frequently prescribed P2Y12 inhibitor (79%), followed by ticagrelor (16%) and prasugrel (4%). Patients prescribed clopidogrel were older and had greater cardiovascular comorbidity. In a propensity-matched cohort of 8,000 patients, 5-year mortality was 28% with clopidogrel versus 27% with ticagrelor (aHR 1.11, 95% CI 1.01 to 1.23; p = 0.04) and 20% with prasugrel (aHR 1.42, 95% CI 1.12 to 1.81; p = 0.004). Ticagrelor was associated with higher 5-year mortality compared to prasugrel (26% vs 20%; aHR 1.49, 95% CI 1.14 to 1.85; p = 0.003). Major bleeding rates did not differ significantly between treatment groups. The risk of readmission with AMI was lower in the clopidogrel group compared to ticagrelor, aHR 0.91 (0.84, 0.99), p = 0.03. In conclusion, clopidogrel remains the predominant P2Y12 inhibitor used in patients with active cancer presenting with AMI. However, ticagrelor and prasugrel were associated with better long-term survival without increased major bleeding. These findings support further evaluation of potent P2Y12 inhibitors in this high-risk population.