How to manage myocardial infarction (MI) in a patient with intracerebral hemorrhage (ICH)?

Management of Myocardial Infarction in a Patient with Intracerebral Hemorrhage

In patients with myocardial infarction (MI) and concurrent intracerebral hemorrhage (ICH), primary percutaneous coronary intervention (PCI) should be the preferred reperfusion strategy with careful avoidance of anticoagulants and antiplatelet agents until the ICH is stabilized and neurosurgical consultation obtained. 1

Initial Assessment and Stabilization

• Immediate brain imaging (CT scan) is mandatory to confirm ICH diagnosis and assess severity before any antithrombotic therapy is initiated 1
• All antiplatelet and anticoagulant therapies should be discontinued immediately upon recognition of ICH 1
• Obtain urgent neurology and/or neurosurgery consultation to guide management decisions regarding the ICH 1
• Consider administering reversal agents if the patient was on prior anticoagulation:
  • For vitamin K antagonists (VKAs): 4-factor prothrombin complex concentrate (PCC) plus intravenous vitamin K 1, 2
  • For direct factor Xa inhibitors: andexanet alfa 1
  • For dabigatran: idarucizumab 1

Blood Pressure Management

• Careful blood pressure control is essential as both conditions have competing goals:
  • For ICH: Consider lowering systolic BP to a target range of 130-140 mmHg if presenting with SBP >150 mmHg 1
  • Avoid lowering SBP below 130 mmHg as this may be potentially harmful in ICH patients 1
  • Use IV agents with short half-life for precise titration to minimize BP variability, which is associated with poor outcomes 1

Reperfusion Strategy for MI

• Primary PCI is strongly preferred over fibrinolysis in patients with ICH 1
• Fibrinolytic therapy is absolutely contraindicated in patients with any prior ICH or active bleeding 1
• During PCI for patients with recent ICH:
  • Consider radial artery access to minimize bleeding risk 1
  • Avoid GP IIb/IIIa inhibitors 1
  • Minimize or avoid periprocedural anticoagulation when possible 1
  • Consider bare metal stents to minimize duration of dual antiplatelet therapy 1

Antithrombotic Management

• Individualize the timing of resumption of antiplatelet and anticoagulant therapy based on:
  • Severity and stability of ICH
  • Risk of MI-related complications (e.g., stent thrombosis)
  • Neurosurgical consultation 1
• Consider single antiplatelet therapy with aspirin alone initially when antiplatelet therapy must be resumed 1
• Delay dual antiplatelet therapy until ICH is stabilized and risk of expansion is minimal 1

Monitoring and Supportive Care

• Monitor for hematoma expansion with serial neuroimaging 1
• Maintain hemoglobin >8 mg/dL, but avoid liberal transfusion strategies unless there is ongoing ischemia 1
• Monitor for cardiac complications, which are common in ICH patients (0.3% have concurrent MI) 1
• Maintain normoglycemia and avoid hyperthermia 1
• Consider ICP monitoring in patients with severe ICH 1

Common Pitfalls to Avoid

• Administering fibrinolytics to patients with ICH, which can be fatal (65% mortality rate with ICH after fibrinolysis) 1
• Delaying reversal of anticoagulation while waiting for lab results - treatment should be initiated based on clinical suspicion 1, 2
• Failing to administer vitamin K along with PCC for VKA reversal, which can lead to rebound increases in INR 1, 2
• Excessive BP lowering (<130 mmHg), which may compromise coronary perfusion and worsen myocardial ischemia 1
• Overlooking the need for early INR testing (within 15-60 minutes) after PCC administration to confirm effective anticoagulation reversal 2