Interventional science was the focus of a Hot Line Session at ESC Congress 2026, with studies shedding light on milvexian with antiplatelet therapy following an acute coronary event; aspirin omission at the time of primary PCI in STEMI; switching from ticagrelor to prasugrel following PCI in patients with acute coronary syndrome (ACS); clopidogrel vs. extended DAPT after high-risk PCI; and potent antiplatelet therapy in patients with atrial fibrillation (AFib) following myocardial infarction (MI).

The LIBREXIA ACS trial, simultaneously published in NEJM, found milvexian did not decrease the risk of cardiovascular death, MI or ischemic stroke, but did not increase the risk of intracranial or fatal bleeding compared with placebo.

“While no effect on efficacy was shown, the absence of an observed increase in intracranial or fatal bleeding is reassuring given that two further trials are ongoing: LIBREXIA AF for patients with [AFib] and LIBREXIA Stroke for secondary stroke prevention,” said Philippe Gabriel Steg, MD, FACC, from Hôpital Bichat in Paris.

In the PREMIUM trial, also published in NEJM, low-dose prasugrel monotherapy initiated before PCI in patients with STEMI was not noninferior to DAPT for 12 months with respect to a composite of death from any cause, stroke or MI at one year. Since noninferiority was not met, the major secondary endpoint related to bleeding was not analyzed.

“These findings do not support prasugrel monotherapy at the time of primary PCI for STEMI,” said Gaku Nakazawa, MD, FACC, from Kindai University in Japan. “It appears that DAPT is needed for at least the first month but the optimum duration of DAPT remains to be determined.”

Researchers presenting results from SWITCH SWEDEHEART, also published in NEJM, said the risk of ischemic events was not lower with a default prasugrel policy than with a default ticagrelor policy in an unselected population of patients with ACS who had undergone PCI.

“In the largest randomized comparison to date, prasugrel offered comparable protection against major cardiovascular events, but with a signal toward less bleeding and lower cost – a potentially important consideration for patients and health care systems,” said Elmir Omerovic, MD, PhD, principal investigator from Sweden.

In a related editorial comment published in NEJM, Rober A. Byrne, MB, BCh, PhD, called SWITCH-SWEDEHEART a landmark policy implementation trial. “The trial adds further weight to support the conduct of pragmatic, registry-based randomized trials of approved medical therapies in patients with ACS,” he said. “The implementation gap that exists between carefully controlled randomized trials and routine clinical practice is real and should always be considered by physicians and policymakers.”

In A-CLOSE, also simultaneously published in NEJM, clopidogrel monotherapy was noninferior to extended DAPT following drug-eluting stent implantation with respect to net adverse clinical events at 24 months in patients at high ischemic risk.

Byeong-Keuk Kim, MD, PhD, et al., said the trial showed a “clear trade-off” in patients at high-ischemic risk. “Extended DAPT provided greater protection against major ischemic events, including death, whereas clopidogrel monotherapy reduced major or clinically relevant bleeding,” he said. “It seems that no single strategy is best for every patient, but rather, long-term antiplatelet therapy should be individualized according to ischemic and bleeding risks, clinical characteristics and treatment preferences in a shared decision-making process between patients and physicians.”

Meanwhile, potent antiplatelet therapy increased bleeding without clear signs of benefit in terms of cardiovascular events in patients with AFib after MI, based on findings from the EPIDAURUS trial.

“In the first trial of its kind, we have answered an important clinical question,” said Konstantinos Rizas, MD, principal investigator. “These findings do not support the routine use of potent P2Y12 inhibitors in combination with direct oral anticoagulants in patients with [AFib] and MI.”

Visit ACC’s ESC Congress 2026 coverage page to explore the latest science and key takeaways shaping cardiovascular care.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Anticoagulation Management and ACS, Interventions and ACS, Interventions and Vascular Medicine, Chronic Angina

Keywords: ESC Congress, ESC26, Acute Coronary Syndrome, Thrombosis, Anticoagulants, Factor Xa Inhibitors, ST Elevation Myocardial Infarction, Myocardial Infarction, Percutaneous Coronary Intervention, Aspirin, Platelet Aggregation Inhibitors, Ticagrelor, Drug Therapy, Combination, Clopidogrel