Too little anticoagulation is its own hazard, and clopidogrel after the first month

The edition in brief

An American Heart Association scientific statement argues that undertreatment with antithrombotics — omission, non-adherence, off-label underdosing and subtherapeutic levels — is a common and under-recognised cause of stroke, systemic embolism, recurrent thrombosis and death in atrial fibrillation, venous thromboembolism and peripheral artery disease, and proposes structured antithrombotic stewardship. A joint 2026 AHA/ACC guideline on perioperative cardiovascular management for non-cardiac surgery formally replaces the 2014 document. The Enlighten registry followed 787 patients given an extravascular ICD with a substernal lead: 89.1% were free of major complications at one year, all 61 spontaneous shocks succeeded, and 7.1% had an inappropriate shock, mostly from non-cardiac oversensing. The practice changer is a prespecified age analysis of TALOS-AMI: among 2697 event-free patients one month after PCI for MI, switching from ticagrelor to clopidogrel reduced net adverse events in those under 75 (4.1% vs 7.2%; aHR 0.54) with no interaction by age, but the result in those aged 75 and over remained uncertain. The pearl covers the label criteria for apixaban dose reduction, the commonest site of DOAC underdosing.