What's Hot in Clots: June 2025

June is here and for those of you in the northern hemisphere, the weather is getting warmer. But I hope you get some time to enjoy the nature and recharge the batteries. Here are this month’s summaries:

Intraprocedural activated clotting time (ACT) targets for PCI: Do we have the OPTIMAL-ACT results? Yes and no

The choice of procedural anticoagulation for patients undergoing PCI is very important. These days, with better PCI techniques, intravascular imaging, and better stents, intra/post-procedural thrombotic risk has declined and there has been a resurgence of interest in bivalirudin over unfractionated heparin because of some recent studies. An equally important question is whether we should still target very high activated clotting times (ACTs) or lower thresholds. The single-center OPTIMAL-ACT trial is very interesting in this regard, although the findings are limited by a small sample size; the trial enrolled roughly a third of the intended target. Read more.

Risk stratification for hemodynamically stable PE: We’re getting better, but is it good enough?

Many tools have been proposed to help with risk stratification in patients with acute PE. The good news is that we have plenty of tools that identify lower risk patients, those who almost certainly don’t deteriorate without advanced treatment (and hence can be discharged on anticoagulation fairly soon). The caveat is most of the existing tools perform poorly in identifying those who tend to do worse! Now, in this study, a previously developed multi-marker tool was validated and shown to outperform the European Society of Cardiology classification criteria. The challenge, IMHO, remains in positive predictive values (PPVs). Even for this new tool, we’re far from optimal outcomes. Important steps forward but more work to be done! Read more.

Incidental acute LAD occlusion: Is that even a thing?

Believe me when I say it, I don’t intend to share case reports every month but some of these are really interesting and eye-opening, at least to me…This time, the authors have described a case where decreased myocardial density on cancer surveillance imaging resulted in cardiac testing and identification of acute left anterior descending (LAD) occlusion that responded well to PCI. The patient was asymptomatic! Read more.

Open vein hypothesis in patients with DVT

A Scientific Statement from the American Heart Association reviews some of the past evidence and shares recommendations and a future perspective on the tradeoffs of interventions to keep veins open, with the goal of reducing long-term complications of deep vein thrombosis (DVT), including post-thrombotic syndrome and its severity. Read more.

LDL and…

Okay, I wouldn’t bother you with LDL and the risk of CAD, or MI, or stroke! This one is about low LDL-C and excess risk of bleeding in patients with VTE! I wonder why. Is it a marker of poor nutritional status that we know can correlate with bleeding? Or is it indicative of low fat reservoirs and there might be a potential interaction with low-molecular-weight heparin? I say so because the study particularly showed a higher risk of hematomas. More to be explored here… Read more.

Behnood Bikdeli, MD, MS