How to manage a patient with acute myocardial infarction (AMI) presenting with hematemesis?

Management of Acute Myocardial Infarction with Hematemesis

In patients with acute myocardial infarction presenting with hematemesis, immediate stabilization of hemodynamics should be prioritized, followed by careful adjustment of antithrombotic therapy while balancing bleeding and thrombotic risks. 1, 2

Initial Assessment and Stabilization

• Hemodynamic stabilization is the first priority, including fluid resuscitation and blood transfusion if needed 2, 3
• Continuous ECG monitoring with defibrillator capacity should be maintained throughout management 1
• Oxygen therapy should be administered if saturation is <90% 1
• Assess the severity of bleeding through clinical parameters (vital signs, hemoglobin levels) and determine if active bleeding is ongoing 2, 3

Diagnostic Approach

• Esophagogastroduodenoscopy (EGD) is indicated and safe in relatively stable post-MI patients to evaluate and potentially treat the source of upper GI bleeding 2
• Routine echocardiography should be performed to assess LV and RV function and detect any mechanical complications 4, 1

Antithrombotic Management

• Temporarily discontinue antiplatelet and anticoagulant therapies during active, severe bleeding until hemostasis is achieved 5
• Once bleeding is controlled, restart antithrombotic therapy as soon as possible, as discontinuation is associated with increased mortality in patients who experienced bleeding 5
• Consider using a proton pump inhibitor (PPI) in combination with dual antiplatelet therapy (DAPT) once antithrombotic therapy is restarted, as this is recommended for patients at high risk of gastrointestinal bleeding 4

Reperfusion Strategy Considerations

• If primary PCI is indicated and patient is hemodynamically stable:

  • Use radial rather than femoral access to minimize bleeding risk 1
  • Consider reduced doses of anticoagulants during the procedure 1
  • Avoid glycoprotein IIb/IIIa inhibitors 4

• If fibrinolytic therapy was being considered:

  • Active GI bleeding is a relative contraindication to fibrinolytic therapy 4
  • Primary PCI is strongly preferred if available 1

Pharmacotherapy Adjustments

• Once hemostasis is achieved, restart essential post-MI medications in a stepwise approach:
  • First, restart low-dose aspirin (75-100 mg) as it has mortality benefit 4, 6
  • Consider using clopidogrel rather than more potent P2Y12 inhibitors (prasugrel or ticagrelor) due to lower bleeding risk 4
  • Beta-blockers should be initiated orally once the patient is hemodynamically stable, particularly in patients with heart failure or LVEF <40% 4, 1
  • ACE inhibitors should be started within 24 hours in patients with heart failure, LV dysfunction, diabetes, or anterior infarct once hemodynamically stable 4, 1
  • High-intensity statin therapy should be initiated as early as possible 4, 1

Long-term Management

• After hospital discharge, maintain a PPI in combination with DAPT as this is strongly recommended for patients with history of GI bleeding 4
• Consider shortening DAPT duration to 6 months in patients at high risk of severe bleeding complications 4
• Regular monitoring for recurrent bleeding and cardiac events is essential 5
• Cardiac rehabilitation should be recommended to all patients after stabilization 4, 1

Common Pitfalls and Caveats

• MI symptoms may be masked by severe GI bleeding, leading to delayed diagnosis and treatment 2
• Severe GI bleeding can precipitate or worsen MI due to hypovolemia and decreased myocardial oxygen supply 2
• Mortality risk is significantly higher in patients with both MI and major bleeding (approximately 1.9 times higher during hospitalization) 5
• Discontinuation of antithrombotic medications in bleeding patients is associated with higher mortality, highlighting the importance of restarting these medications once bleeding is controlled 5