What is the management approach for a patient with hematemesis (vomiting blood) and ST-Elevation Myocardial Infarction (STEMI) where Percutaneous Coronary Intervention (PCI) is not possible?

Management of Hematemesis with STEMI When PCI is Not Possible

In patients with hematemesis and STEMI where PCI is not possible, fibrinolytic therapy should be administered if there are no contraindications to fibrinolysis, with careful consideration of bleeding risk given the active gastrointestinal bleeding. 1

Initial Assessment and Stabilization

• Evaluate the severity of hematemesis and hemodynamic stability - active GI bleeding is a relative contraindication to aggressive antithrombotic therapy but must be balanced against the mortality risk of untreated STEMI 1
• Assess the time from symptom onset, as this will influence reperfusion strategy decisions 1
• Obtain baseline hemoglobin levels and coagulation parameters to guide therapy 1
• Consider blood transfusion only if hemoglobin is <8 mg/dL unless there is ongoing ischemia 1

Reperfusion Strategy Decision Algorithm

When Fibrinolysis is Appropriate:

• If hematemesis is mild to moderate and controlled, and the bleeding risk is deemed acceptable, administer fibrinolytic therapy as the primary reperfusion strategy 1
• The decision to use fibrinolysis should consider the mortality risk of STEMI against the risk of worsening GI bleeding 1
• For patients with cardiogenic shock and hematemesis where PCI is not possible, fibrinolytic therapy is still recommended if there are no absolute contraindications 1

Antiplatelet Therapy Considerations:

• Administer aspirin at a lower dose (81 mg) to minimize GI irritation 1
• Consider clopidogrel loading dose (300 mg) followed by 75 mg daily maintenance if the GI bleeding is controlled 2
• Avoid prasugrel or ticagrelor due to higher bleeding risk in patients with active GI bleeding 1

Anticoagulation Management:

• Use unfractionated heparin (UFH) rather than low molecular weight heparin as it has a shorter half-life and can be reversed if bleeding worsens 1
• Consider lower doses of anticoagulants with frequent monitoring of activated clotting time 1
• Avoid fondaparinux as the sole anticoagulant as it has been shown to be harmful in this setting 1

Post-Fibrinolysis Management

• Monitor for signs of reperfusion and hemodynamic stability 1
• If the patient is high-risk (extensive ST elevation, previous MI, Killip class >2, LVEF ≤35%), consider transfer to a PCI-capable facility once hematemesis is controlled 1
• For patients who are not high-risk, continue medical management with careful monitoring for recurrent ischemia or bleeding 1

Special Considerations

• If hematemesis is severe and ongoing, prioritize GI bleeding management before considering reperfusion therapy 3
• Consider emergency endoscopy to identify and potentially treat the source of bleeding before administering fibrinolytic therapy 1
• For patients with cardiogenic shock, an intra-aortic balloon pump may be considered to improve coronary perfusion while minimizing antithrombotic therapy 1

Pharmacological Management

• Use proton pump inhibitors to reduce the risk of continued GI bleeding 3
• Consider H2 receptor antagonists as an alternative if there are concerns about PPI interactions with clopidogrel 2
• Avoid NSAIDs and other medications that may increase bleeding risk 2

Transfer Considerations

• Once hematemesis is controlled, immediate transfer to a PCI-capable facility should be arranged 1
• During transfer, maintain appropriate antithrombotic therapy based on the patient's bleeding risk 1
• Communicate clearly with the receiving facility about the patient's hematemesis history and current status 1

Long-term Management

• After the acute phase, consider bare-metal stents rather than drug-eluting stents if PCI becomes possible, as they require a shorter duration of dual antiplatelet therapy 1
• For patients who received fibrinolysis, consider coronary angiography within 24 hours once the GI bleeding is controlled 1
• Implement secondary prevention measures with careful consideration of bleeding risk 1