OCEANIC-STROKE: Rethinking Secondary Stroke Prevention with Dr. Mike Sharma

Send us Fan MailFor decades, antiplatelet therapy has been central to secondary prevention following noncardioembolic ischemic stroke. Could factor XIa inhibition offer another approach?Dr. Mike Sharma, principal investigator and first author of OCEANIC-STROKE, joins Dr. Maha Othman and Dr. Jameel Abdulrehman to discuss the phase 3 trial of asundexian for secondary stroke prevention.OCEANIC-STROKE randomized 12,327 patients with noncardioembolic ischemic stroke or high-risk TIA to asundexian or placebo in addition to antiplatelet therapy. Ischemic stroke occurred in 6.2% of patients receiving asundexian versus 8.4% receiving placebo, while rates of ISTH major bleeding were similar.The discussion explores why factor XIa is an attractive therapeutic target, the clinical implications and limitations of the results, patient selection, and why factor XIa inhibition may challenge conventional thinking about antithrombotic therapy.This episode was made possible through financial support from Bayer Inc. Thrombosis Canada maintained full editorial independence, and Bayer had no involvement in the selection of the guest, development of the questions, conduct of the interview, or review or approval of the final content.Sharma M, Dong Q, Hirano T, Kasner SE, Saver JL, Masjuan J, Demchuk AM, Cordonnier C, Bereczki D, Tsivgoulis G, Veltkamp R. Asundexian for secondary stroke prevention. New England Journal of Medicine. 2026 Apr 16;394(15):1467-79.Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailDr. Lana Castellucci and Dr. Kerstin de Wit join CLOT Conversations to discuss the 2026 guideline for the evaluation and management of acute pulmonary embolism in adults and what its recommendations mean for clinical practice.The conversation explores the new A–E clinical categories for acute PE, including how to recognize patients whose condition may be deteriorating despite not meeting traditional criteria for high-risk PE. The discussion also covers the role of PE response teams (PERT), outpatient versus inpatient management, the recommendation for low-molecular-weight heparin over IV unfractionated heparin when parenteral therapy is required, and patient selection for systemic thrombolysis and catheter-directed therapies.The guests also address a common patient question about flying after PE, important evidence gaps, and a fundamental clinical message: avoid unnecessary delays in anticoagulation while determining next steps.Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2026 Mar 24;153(12):e977-e1051. doi: 10.1161/CIR.0000000000001415. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001415Hosts: David Airdrie, Dr. Jameel Abdulrehman and Dr. Maha Othman.Visit thrombosiscanada.ca for clinical guides, tools, education and patient resources.Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailIs aspirin alone enough to prevent venous thromboembolism after total hip or knee arthroplasty?In this episode of CLOT Conversations, Dr. Jameel Abdulrehman speaks with Dr. Sudeep Shivakumar, lead author of the EPCAT III trial, recently published in the New England Journal of Medicine.EPCAT III randomized more than 5,400 patients undergoing hip or knee arthroplasty to receive aspirin alone or rivaroxaban for five days followed by aspirin. Dr. Shivakumar discusses the study's findings, including the low rates of symptomatic VTE observed in both groups, bleeding outcomes, the significance of distal DVT, and how EPCAT III builds on the earlier EPCAT trials.They also explore whether modern surgical care has changed the baseline risk of VTE following arthroplasty and which higher-risk patients may still warrant an anticoagulant-based approach.A practical discussion about translating an important Canadian clinical trial into individualized thromboprophylaxis decisions.Reference:Shivakumar, Sudeep, et al. "Rivaroxaban Then Aspirin vs. Aspirin Alone after Total Hip or Knee Arthroplasty." New England Journal of Medicine (2026). https://www.nejm.org/doi/abs/10.1056/NEJMoa2603649Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailHormone therapy is used across a wide range of clinical settings—from contraception and menopause management to pregnancy care and gender-affirming therapy. But how do these treatments influence thrombosis risk, and how should clinicians approach these decisions in practice?In this episode of CLOT Conversations, hosts Dr. Jameel Abdulrehman and Dr. Maha Othman speak with Dr. Leslie Skeith and Dr. Shannon Bates about their recent New England Journal of Medicine review on sex hormone influences on venous thrombotic and cardiovascular risk.The discussion explores the thrombotic effects of estrogen, progestogens, and testosterone; differences between hormone formulations; management considerations for patients with prior thrombosis; gender-affirming hormone therapy; and practical approaches to perioperative care.Whether you care for patients receiving contraception, hormone replacement therapy, or gender-affirming care, this episode provides evidence-based guidance to support informed clinical decision-making.For the full publication: https://www.nejm.org/doi/abs/10.1056/NEJMra2202438Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailPost-thrombotic syndrome (PTS) affects up to half of patients following deep vein thrombosis and can significantly impair quality of life. Yet treatment options have historically been limited.In this episode of CLOT Conversations, David Airdrie and Dr. Jameel Abdulrehman speak with Dr. Susan Kahn about the recently published C-TRACT trial in The New England Journal of Medicine.The trial evaluated whether endovascular therapy, including iliac vein stenting, could improve outcomes for patients with moderate-to-severe post-thrombotic syndrome and iliac vein obstruction.Dr. Kahn discusses the rationale behind the study, key findings related to symptom burden and quality of life, the increased bleeding risk observed with intervention, practical patient selection considerations, and the unanswered questions that remain regarding long-term management after venous stenting.This episode provides clinicians with practical insights into one of the most important recent studies in the management of post-thrombotic syndrome.Reference:Vedantham S, Kahn SR, Marston WA, Weinberg I, Sista AK, Magnuson EA, Cohen DJ, Wasan SM, Razavi MK, Goldhaber SZ, Sanfilippo KM. Endovascular Therapy for Post-Thrombotic Syndrome—A Randomized Trial. New England Journal of Medicine. 2026 Apr 13.https://www.nejm.org/doi/abs/10.1056/NEJMoa2519001Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailPerioperative anticoagulation management is a common and complex clinical challenge. In this episode of CLOT Conversations, Drs. James Douketis and Joseph Shaw discuss new ISTH guidance on surgical and procedural bleed risk stratification in anticoagulated patients.The discussion explores why updated guidance was needed, addressing inconsistencies in prior schemas, and introduces a more detailed, procedure-specific framework. The authors outline a three-tier classification—minimal, low/moderate, and high bleed risk—and its implications for anticoagulation management.The episode focuses on real-world application, including patient-specific factors, procedural variability, and interdisciplinary communication. It also highlights evidence gaps and ongoing research such as PAUSE2 and ACE-HIGH.https://www.jthjournal.org/article/S1538-7836(26)00055-3/abstract [Subscription required for full paper]Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailWhich DOAC bleeds less in acute VTE?In this episode, we explore the COBRRA trial comparing apixaban vs rivaroxaban and what it means for clinical practice.The COBRRA trial provides the first direct, randomized comparison of apixaban and rivaroxaban for the treatment of acute venous thromboembolism (VTE).In this episode of CLOT Conversations, Dr. Lana Castellucci discusses findings from this landmark study and how they should influence anticoagulant selection.Key insights include:Apixaban reduced clinically relevant bleeding by more than 50% compared to rivaroxabanDifferences in bleeding risk emerged early and persisted over the 3-month treatment periodRecurrent VTE and mortality rates were similar between groupsDosing strategies and early treatment phase appear to play a key roleWe also explore real-world considerations, including medication adherence, patient preference, and how to approach populations not included in the trial, such as cancer-associated thrombosis and higher body weight.This episode provides practical, evidence-based guidance for clinicians managing acute DVT and pulmonary embolism. Listen now to learn how the COBRRA trial may change your approach to DOAC selection.Access the publication here:Castellucci LA, Chen VM, Kovacs MJ, Lazo-Langner A, Greenstreet P, Kahn S, Côté B, Schulman S, De Wit K, Douketis J, Suryanarayan D. Bleeding risk with apixaban vs. rivaroxaban in acute venous thromboembolism. New England Journal of Medicine. 2026 Mar 12;394(11):1051-60.Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailMajor bleeding remains the principal complication of oral anticoagulation. In patients with device-detected subclinical atrial fibrillation, the decision to anticoagulate requires careful balancing of stroke prevention against bleeding risk.In this episode of CLOT Conversations, Dr. Deborah Siegal discusses a prespecified subanalysis of the ARTESiA randomized clinical trial, recently published in JAMA Cardiology. ARTESiA demonstrated a 37% reduction in stroke and systemic embolism with apixaban compared to aspirin — but at the cost of increased major bleeding.This subanalysis goes deeper, examining the site, severity, and clinical course of bleeding events. Most bleeding was gastrointestinal and non-critical. Rates of intracranial and fatal bleeding were low and similar between treatment arms. The majority of events were not clinical emergencies, and many were defined by hemoglobin decline rather than catastrophic presentation.We explore what these findings mean for individualized risk assessment, the importance of modifiable bleeding risk factors such as NSAID use, and how physicians and patients can approach shared decision-making in subclinical AF.Abstract (subscription required for full paper): Siegal DM, Sticherling C, Healey JS, McIntyre WF, Christensen LS, Parkash R, Vanassche T, Conen D, Gold M, Granger CB, Nielsen JC. Major Bleeding With Apixaban vs Aspirin: A Subanalysis of the ARTESiA Randomized Clinical Trial. JAMA cardiology. 2025 Dec;10(12):1305-14.https://jamanetwork.com/journals/jamacardiology/fullarticle/2841075Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailObesity presents a persistent challenge in the management of cancer-associated thrombosis, particularly when prescribing low molecular weight heparin beyond standard dose caps.In this episode of CLOT Conversations, host Dr. Jameel Abdulrehman is joined by Dr. Tzu-Fei Wang and Dr. Grégoire Le Gal to discuss findings from the WAVe study, a multicenter prospective cohort study evaluating weight-adjusted dalteparin dosing in patients over 90 kg with acute cancer-associated venous thromboembolism.The conversation examines bleeding and thrombotic outcomes, mortality, and trough anti-Xa levels, including insights into bioaccumulation and twice-daily versus once-daily dosing. The guests also address study limitations, dose capping in patients with very high body weight, and how WAVe fits into current practice amid increasing DOAC use.This episode provides practical, evidence-informed guidance for clinicians navigating anticoagulation decisions in obese patients with cancer.To access the full publication:  https://onlinelibrary.wiley.com/doi/full/10.1002/ajh.70127 Please consider supporting Thrombosis Canada by donating today or consider a monthly donation starting at $10: ThrombosisCanada.ca/donateSupport the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada

Send us Fan MailIn this episode of CLOT Conversations, co-hosts Dr. Jamil Abdul-Rahman and Dr. Maha Othman have an in-depth discussion with leading thrombosis expert Dr. Jeff Weitz. Together, they unpack new findings from The Lancet on RGN-9933 and RGN-7508, two investigational factor XI inhibitors evaluated in the ROXI-VTE I and II phase-2 trials. These studies examine how targeted inhibition of factor XI may reduce post-operative venous thromboembolism with potentially lower bleeding risk than current anticoagulants.Dr. Weitz explains the distinct mechanisms of the two antibodies, the role of factor XII-mediated activation in post-operative VTE, key efficacy and safety outcomes, and how these early-phase studies set the stage for ongoing phase-2 and phase-3 trials—including ROXI-CATH, ROXI-Aspirin, and emerging AF and stroke-prevention research.This episode is essential listening for clinicians interested in the rapidly evolving landscape of anticoagulation and next-generation therapies that may offer safer options for patients undergoing orthopedic surgery and beyond.Read the full Lancet publication by clicking on the link below and explore more thrombosis resources at thrombosiscanada.ca.Become a Thrombosis Champion, be a monthly donor at https://thrombosiscanada.ca/donatehttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)02097-5/abstract [Note: full access requires a subscription]Support the showhttps://thrombosiscanada.caRegister today for our upcoming conference on November 7, 2026 in Montreal at https://thrombosiscanada.ca/2026ConferenceTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada