What's Hot in Clots: September 2026

Me and my childhood? As we come toward the end of summer, let me confess that I always loved studying but felt that the summers were too short! Now back to articles and summaries…I found it quite difficult this month since there were too many good ones to cover. Alas, I can cover only so much. Here we go:

HALT! It’s DOAC time after TAVR!

Okay, I’m referring to hypo-attenuated leaflet thickening (HALT). Prior randomized controlled trials (RCTs) have shown that using direct oral anticoagulants (DOACs) ad-hoc alongside antiplatelet therapy after transcatheter aortic valve replacement (TAVR) may cause more harm than good.

Now we have two new RCTs that evaluated DOACs either for three or twelve months instead of single antiplatelet therapy. They both showed that DOACs reduced HALT during active treatment. However, in the first trial, the favorable effect faded away, and other clinical events started moving in the wrong direction. I don’t think we have a clear winner, yet…

Liberated from ACS troubles? Not quite…

Findings from the long-awaited LIBREXIA-ACS trial were presented at ESC and published simultaneously. The trial randomized 14,194 patients with recent acute coronary syndrome (ACS) to the factor XIa inhibitor milvexian or placebo, added to standard antiplatelet therapy. A prespecified interim analysis conducted after 556 adjudicated primary efficacy events found no efficacy signal with milvexian (hazard ratio, 1.05), prompting the trial’s early termination for futility.

Milvexian was not associated with an increase in severe or fatal bleeding compared with placebo. Ummm…would that matter much if it showed no efficacy signal over placebo? I don’t know what the future holds for this drug class, but the enthusiasm has certainly dampened compared with six years ago. Read more.

An Hb decline in patients receiving oral anticoagulation [for AF]...could it be cancer?

This one really resonated with me. It’s not rocket science, but I found it quite helpful and practical. In a study largely using claims data and some laboratory values, the authors show that a drop in hemoglobin in patients with atrial fibrillation (AF) who receive anticoagulants may be a sign for hidden cancer. Something to watch for…read more.

Should we consider anticoagulation in patients with AF at intermediate risk of stroke?

This new RCT evaluated anticoagulation with a DOAC vs. no anticoagulation in patients with AF who were at intermediate risk of ischemic stroke (and hence not traditionally qualifying for anticoagulation). Bottom line, there was a significant reduction in the risk of stroke systemic embolism, major bleeding, or cardiovascular death (hazard ratio: 0.31)—but the magnitude of benefit seems small. So, the key will be future related substudies to show which patients benefit the most from anticoagulation. Read more.

Fifth Universal Definition of Myocardial Infarction (UDMI)

In my opinion, I saved the most important update for last. Think of this as a placeholder since I’d have to write a long summary to do justice to the long-awaited UDMI V. Briefly, the whole MI classification has changed to a 3-category grouping of primary, secondary, and procedure-related MI, with major implications for research and practice. Read more.