What's Hot in Clots: May 2026

My goodness, instead of “What’s Hot in Clots,” I should ask myself “What’s NOT Hot in Clots” this month! So many cool papers—I really had to choose! My wishes and prayers for prevailing peace and a better life for people continue. How about this? Hot clots, warmer weather, and a cool and calm world.

Dr. Braunwald, the greatest cardiologist of all time, dies at 96

This news was so hard for me—he was my superhero. Not young by chronological age, so not quite unexpected if I were to rationalize it as a physician…but he was an icon and likely the most influential clinician-investigator in the history of modern cardiovascular medicine. He made amazing contributions to many diseases/conditions, including but not limited to, thrombotic diseases. I was fortunate to learn from his wisdom for two recent papers on fibrinolytic therapy. He was absolutely brilliant, and it was one of the highlights of my career. I can't share a single link but feel free to look him up and learn about his amazing personal journey to escape Austria (“it was like the Sound of Music, except there was no music,” he once said), to pushing the boundaries in cardiovascular medicine every step of his career. We will really miss him.*

A whole issue of JACC dedicated to PE and the 2026 AHA/ACC PE guideline! What just happened?!

As best as I can recall, it’s the first time that a major cardiovascular journal—or any high-impact journal for that matter—dedicated an entire issue cover to cover on pulmonary embolism. I’m obviously very biased because I was involved in curating that issue but still think that JACC and ACC should receive a lot of credit for it. With cardiovascular specialists being involved in many elements of PE care, from diagnosis to prognostication and (advanced) therapies, an AHA/ACC guideline was long overdue. Here it is! It’s a full issue and I can’t showcase all pieces…but briefly:

• Some share original data, including the burden of PE in the US, trends in 90-day outcomes for patients with PE, trends in use of thrombectomy vs fibrinolysis for PE, and trends in mortality for those with high-risk PE.

• Other pieces from the Writing Committee, e.g., on the AHA/ACC Clinical Categories, or use of advanced therapies.

• Insights from independent experts, for example, related to sex/pregnancy considerations, supportive and critical care, post-PE syndrome, and other geographic perspectives, such as the Asia Pacific region.

• Finally, there’s a thoughtful commentary on how the new guidance can catalyze medical education.

Endovascular therapy for patients with iliac involvement and post-thrombotic syndrome?

In my practice, I always respect the iliac DVTs more than those distal to the iliac veins–and the elegant C-TRACT trial put that beyond any doubt. In those with iliac vein stenosis/obstruction and moderate-to-severe post-thrombotic syndrome, endovascular repair plus medical therapy was superior to medical therapy alone, resulting in reduced severity of post-thrombotic syndrome and better life quality. Endovascular repair, by protocol, was associated with intensification of the antithrombotic regimen and therefore resulted in more bleeding events. Bonus point, Kathryn from VLN, was a coauthor! Read more.

An OCEAN of hope….and uncertainty in managing noncardioembolic ischemic stroke

To add to the continued saga on factor XI/XIa inhibitors, we now present a “positive” trial. OCEANIC STROKE, unlike OCEANIC AF, showed a significant reduction in future stroke events and composite ischemic events without a significant increase in major bleeding. Fatal bleeding, albeit rare, was more frequent with asundexian than placebo (14 vs 8 events). Clinically, I have two takeaways: First, I’m glad to see that there will be a potential new option for patients to consider. Second, the absolute risk reduction seems modest and accrues over long-term follow-up. The question in my mind is whether this is a regimen that is truly superior to the (now generic) COMPASS regimen, which one can consider several months after an initial event. Read more.

Return of the V/Q? It’s a matter of SPECTACULAR perspective!

Considering plain old (AKA planar) Ventilation-Perfusion (V/Q scan) for the diagnosis of PE in 2026 makes me look like a dinosaur! But the SPECTACULAR trial was more interesting than that! In an open-label randomized trial, the investigators compared planar V/Q, Computed Tomography Pulmonary Angiography (CTPA), and the new form of V/Q imaging (i.e., V/Q SPECT – Single Photon Emission Computed Tomography). The outcome? Although V/Q SPECT didn’t quite hit the non-inferiority threshold, its failure rate was very low, giving hope for a promising alternative when we need one. Read more.

*To read more about Dr. Braunwald's incredible life and legacy, check out VLN's Titans of Thrombosis series here.