How to manage Non-ST Elevation Myocardial Infarction (NSTEMI) with upper Gastrointestinal (GI) bleed?

Management of Non-ST Elevation MI with Upper GI Bleed

For patients with NSTEMI complicated by upper GI bleeding, an individualized approach balancing the risks of thrombosis versus bleeding is recommended, with early invasive strategy for high-risk patients after hemodynamic stabilization and control of bleeding. 1

Initial Assessment and Stabilization

• Perform immediate hemodynamic assessment and resuscitation with intravenous fluids to maintain adequate blood pressure and tissue perfusion 2, 3
• Transfuse red blood cells at a hemoglobin threshold of 7-8 g/dL to maintain oxygen delivery to tissues while avoiding excessive transfusion 4, 3
• Administer high-dose proton pump inhibitors (PPIs) intravenously to stabilize clots and reduce risk of continued or recurrent bleeding 4, 3
• Consider erythromycin infusion before endoscopy to improve visualization 4

Risk Stratification

• Assess cardiac risk using validated tools such as GRACE score to determine optimal timing of intervention 1
• Evaluate GI bleeding severity using scoring systems like Glasgow-Blatchford score 4, 3
• Higher risk NSTEMI features include: hemodynamic instability, refractory ischemia, electrical instability, elevated troponins, and dynamic ECG changes 1

Endoscopic Management

• Perform upper endoscopy within 24 hours after hemodynamic stabilization to identify and treat the source of bleeding 4, 3
• Endoscopic therapy should be performed for ulcers with active bleeding or non-bleeding visible vessels 4
• Options include bipolar electrocoagulation, heater probe, clips, or injection therapy 4

Antithrombotic Management

Antiplatelet Therapy

• Continue aspirin at low dose (81 mg daily) if possible, as it has the most favorable risk-benefit profile 1
• Consider temporarily discontinuing P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) during active bleeding, with the shortest possible interruption based on endoscopic findings and cardiac risk 1
• For patients with recent stent placement, the decision to continue dual antiplatelet therapy despite GI bleeding should be made based on stent thrombosis risk versus bleeding severity 1, 5

Anticoagulation

• Discontinue parenteral anticoagulants (UFH, LMWH, fondaparinux) during active bleeding 1
• Resume anticoagulation after bleeding is controlled, with timing based on the severity of bleeding and risk of thrombotic events 1

Cardiac Management

• For high-risk NSTEMI patients with controlled GI bleeding, an early invasive strategy (within 24 hours) is recommended 1
• For initially stabilized patients with controlled bleeding, an early invasive approach (within 24 hours) is reasonable if they have high-risk features 1
• For lower-risk patients or those with ongoing bleeding concerns, a delayed invasive or selective invasive approach may be considered 1

Post-Endoscopic Management

• Resume high-dose PPI therapy for 72 hours after successful endoscopic hemostasis, followed by twice-daily oral PPI for at least 2 weeks 4
• Restart antiplatelet therapy as soon as the risk of cardiac events outweighs the risk of recurrent bleeding 1
• Consider using proton pump inhibitors in patients requiring triple antithrombotic therapy (anticoagulant plus dual antiplatelet therapy) 1

Special Considerations

• For patients requiring long-term anticoagulation plus antiplatelet therapy, minimize the duration of triple therapy to reduce bleeding risk 1
• Consider a lower target INR (2.0-2.5) for patients requiring warfarin plus antiplatelet therapy 1
• For patients with recurrent GI bleeding on dual antiplatelet therapy, consider switching to a regimen with lower bleeding risk (e.g., clopidogrel instead of prasugrel) 1

Common Pitfalls to Avoid

• Delaying endoscopy beyond 24 hours in a hemodynamically stable patient 4, 3
• Premature discontinuation of all antithrombotic therapy in patients with recent coronary stenting, which significantly increases stent thrombosis risk 1, 5
• Excessive blood transfusion (target Hb >9 g/dL), which may increase myocardial oxygen demand and worsen cardiac outcomes 4, 3
• Failing to restart antiplatelet therapy after bleeding control, particularly in high cardiac risk patients 1