How to manage myocardial infarction (MI) with gastrointestinal (GI) bleeding?

Management of Myocardial Infarction with Gastrointestinal Bleeding

In patients with concurrent MI and GI bleeding, aspirin for secondary prevention should be continued or restarted as soon as hemostasis is achieved, while P2Y12 inhibitors should be temporarily interrupted but reinstated within 5 days, with management coordinated with a cardiologist. 1

Initial Assessment and Stabilization

• Assess hemodynamic status immediately and begin intravascular volume resuscitation as needed, with red blood cell transfusion for hemoglobin levels below 70 g/L (or below 80 g/L in patients with cardiovascular disease) 1
• For patients with cardiovascular disease, use a higher hemoglobin threshold of 80 g/L and a target of 100 g/L after transfusion 1
• Initiate intravenous proton pump inhibitors for upper GI bleeding 1
• Arrange for urgent endoscopy after stabilization, which should not be delayed for mild to moderate coagulopathy 1

Antiplatelet Management in MI with GI Bleeding

Aspirin

• For primary prevention: Permanently discontinue aspirin 1
• For secondary prevention (most MI patients): Do not routinely stop aspirin; if stopped during active bleeding, restart as soon as hemostasis is achieved 1

P2Y12 Inhibitors (Clopidogrel, Ticagrelor, Prasugrel)

• In patients with coronary stents: Do not routinely stop dual antiplatelet therapy (DAPT) 1
• In unstable/active bleeding: Consider temporarily interrupting the P2Y12 inhibitor while continuing aspirin 1
• P2Y12 inhibitor therapy should be reinstated within 5 days to prevent stent thrombosis 1
• Liaison with a cardiologist is essential for management decisions 1

Anticoagulant Management

• Interrupt warfarin therapy at presentation 1
• For unstable GI hemorrhage on warfarin: Reverse anticoagulation with prothrombin complex concentrate and vitamin K 1
• For patients with low thrombotic risk: Restart warfarin at 7 days after hemorrhage 1
• For patients with high thrombotic risk (mechanical heart valves, atrial fibrillation with valvular disease): Consider low molecular weight heparin at 48 hours after hemorrhage 1
• For direct oral anticoagulants (DOACs): Interrupt at presentation and consider restart at maximum 7 days after hemorrhage 1

Special Considerations

Timing of Endoscopy

• Perform endoscopy within 24 hours after adequate colon preparation for lower GI bleeding 2
• For upper GI bleeding, early endoscopy is beneficial but should be performed after hemodynamic stabilization 1, 3
• Patients who are hemodynamically unstable before endoscopy have significantly higher complication rates (37.5% vs 0%) 3

Risk of Stent Thrombosis

• Discontinuation of both antiplatelet agents in the setting of recent stent placement significantly increases the risk of stent thrombosis 1
• The risk is particularly high within the first month after stent placement 1
• Patients with drug-eluting stents have prolonged risk of stent thrombosis compared to bare-metal stents 4

Mortality Considerations

• GI bleeding following MI is associated with increased mortality (HR 2.86) 5
• Simultaneous GI bleeding and MI has a higher mortality rate (33%) compared to either condition alone 6
• Dual antiplatelet therapy is the most powerful predictor of GI bleeding in post-MI patients (HR 3.18) 7

Algorithm for Management

1. Immediate stabilization:

   • Fluid resuscitation and blood transfusion (Hb target 70-90 g/L, or 80-100 g/L with cardiovascular disease) 1
   • IV proton pump inhibitors 1

2. Antiplatelet decision:

   • Continue aspirin if possible (for secondary prevention) 1
   • If both agents must be stopped due to severe bleeding, restart aspirin first as soon as hemostasis is achieved 1
   • Restart P2Y12 inhibitor within 5 days 1

3. Endoscopic management:

   • Perform endoscopy after stabilization 1, 3
   • Apply appropriate endoscopic hemostasis techniques 2

4. Post-endoscopy care:

   • Resume antithrombotic therapy according to thrombotic vs. bleeding risk 1
   • Consider prophylactic PPI therapy for patients requiring ongoing antiplatelet therapy 1
   • Monitor for rebleeding and signs of cardiac ischemia 1

Common Pitfalls and Caveats

• Completely stopping both antiplatelet agents in patients with recent coronary stents can lead to catastrophic stent thrombosis 1
• NSAIDs increase the risk of GI bleeding when coadministered with clopidogrel and should be avoided 8
• Proton pump inhibitors (particularly omeprazole and esomeprazole) may reduce the antiplatelet activity of clopidogrel, but this interaction should not prevent their use when indicated for GI protection 1, 8
• Patients with MI and GI bleeding may present with atypical symptoms; chest pain may be absent, and syncope, dizziness, or confusion due to hypovolemia may be the predominant symptoms 6