Clinical Case 31—Active gastrointestinal bleeding during STEMI: a management dilemma

A man in his 40s presented to the emergency department with chest pain for 8 hours. ECG showed an anterior wall ST-segment elevation myocardial infarction (MI). He received a loading dose of both aspirin and ticagrelor. Coronary angiography demonstrated occlusion of the proximal left anterior descending artery, and primary percutaneous coronary intervention (PCI) with one drug-eluting stent was performed.

The patient also presented melena for 5 days. At admission, his hemoglobin was 6.3 g/dL and he was stable. He received a blood transfusion and was started on IV pantoprazole. Endoscopic study was postponed due to concerns related to performing such exam in the setting of a recent MI.

The day after PCI, the patient presented major bleeding and hypotension, leading to interruption of the P2Y12 inhibitor. On day 3 of hospitalization, while on single antiplatelet therapy with aspirin, the patient presented new onset of chest pain. He was diagnosed with subacute stent thrombosis (type 4b MI), and thrombus aspiration and balloon angioplasty were performed (Figure 1A, and B). Dual antiplatelet therapy was immediately restarted. Echocardiography revealed worsened left ventricular disfunction (LVEF of 20%). Endoscopy showed tears in the esophagogastric junction (Mallory-Weiss syndrome).

This case challenged clinical decision-making, especially the antithrombotic strategy after primary PCI in a patient with major bleeding.

Learning points

Management of a bleeding patient with acute MI should be individualized. The decision to withhold antithrombotic treatment should weigh the risks related to ongoing bleeding and stent thrombosis.

Figure 1

Coronary angiography. A—Total occlusion with in-stent thrombus in the proximal left anterior descending artery. B—After thrombus aspiration and angioplasty with paclitaxel-coated balloon of stent thrombosis in the proximal left anterior descending artery, remaining a residual lesion of 50–70%, and distal flow TIMI grade 3.