Background and aims: Patients with inflammatory bowel disease (IBD) are at increased risk of acute arterial events. Treatment with anti-tumor necrosis factor agents (anti-TNF) has been associated with a protective effect against the first occurrence of acute arterial events, but the impact of treatment with anti-TNF in patients with a previous history of acute arterial events has not been assessed until now. We assessed the effect of anti-TNF and thiopurines on the risk of recurrent acute arterial events in patients with IBD in a nationwide cohort. Methods: Based on the French nationwide health insurance database, patients with IBD and a previous history of an acute arterial event were followed from January 1, 2009 until December 31, 2018. The risk of acute arterial event recurrence associated with anti-TNF and thiopurines exposures was assessed using marginal structural Cox proportional hazard models adjusted for baseline and time-varying covariates. Results: A total of 27 185 patients were included. During 121 822 person-years (median follow-up 4.0 years), 6 865 recurrent acute arterial events occurred (incidence rate per 1000 person-years, 56.4; 95% CI, 55.0-57.7). Both exposure to anti-TNF and thiopurines were associated with a decreased risk of recurrent acute arterial events compared to the absence of exposure to either treatment (HR 0.75; 95% CI 0.63-0.90 and HR 0.76; 95% CI 0.66-0.88, respectively). Conclusions: In a nationwide cohort study of patients with IBD and a previous history of acute arterial event, both exposure to anti-TNF and thiopurines were associated with a decreased risk of recurrent acute arterial events.