How to manage gastrointestinal bleeding in an elderly patient on enoxaparin, aspirin, and ticagrelor after myocardial infarction with non-obstructive coronary arteries?

Management of Melena in Elderly MINOCA Patient on Triple Antithrombotic Therapy

Stop enoxaparin immediately and continue aspirin while temporarily holding ticagrelor until hemostasis is achieved, then resume ticagrelor within 24-48 hours given the recent MINOCA event. 1, 2

Immediate Actions

Discontinue Anticoagulation

• Stop enoxaparin immediately as it is the most reversible component and contributes significantly to bleeding risk in triple therapy 2, 3
• Enoxaparin has a half-life allowing platelet function recovery within 12-24 hours after discontinuation 2
• Do not restart enoxaparin unless there is a separate indication for therapeutic anticoagulation 2

Manage Antiplatelet Therapy Strategically

• Continue aspirin 75-100 mg daily without interruption to maintain baseline cardiovascular protection 4, 1
• Hold ticagrelor temporarily until bleeding is controlled, as it is reversible with platelet function returning within 3-5 days 4, 1
• The combination of continuing aspirin while holding ticagrelor provides the optimal balance between thrombotic and bleeding risk in acute GI bleeding 4

Bleeding Management

Initiate Proton Pump Inhibitor Therapy

• Start high-dose intravenous PPI (e.g., pantoprazole 80 mg IV bolus followed by 8 mg/hour infusion) immediately 4
• PPIs are specifically recommended for patients at high risk of GI bleeding on antithrombotic therapy 4
• Continue PPI therapy long-term once bleeding controlled, as this significantly reduces recurrent GI bleeding risk (age-adjusted OR 0.068) 3

Perform Early Endoscopy

• Arrange urgent upper endoscopy within 24 hours to identify bleeding source and achieve endoscopic hemostasis 4, 5
• Early endoscopy is the standard of care for acute upper GI bleeding in antiplatelet-treated patients 4, 5
• Do not delay endoscopy to normalize coagulation parameters, as INR/anticoagulation status does not predict outcomes 4

Apply Local Hemostatic Measures

• Aggressive endoscopic hemostasis techniques should be employed (clips, thermal therapy, injection therapy) 4, 5
• Consider adjunctive hemostatic agents such as tranexamic acid if bleeding is severe, though this does not reverse antiplatelet effects 1

Resuming Antithrombotic Therapy

Timing of Ticagrelor Resumption

• Resume ticagrelor within 24-48 hours after achieving hemostasis given this is day 3 post-MINOCA, placing the patient in the highest-risk window for recurrent ischemic events 1, 4
• For patients within 30 days of acute coronary syndrome, ticagrelor should be resumed as soon as hemostasis is achieved to minimize thrombotic risk 1, 4
• Ticagrelor's reversible mechanism allows for safer earlier resumption compared to clopidogrel or prasugrel (which require 5-7 days for platelet recovery) 4, 1

Duration of Dual Antiplatelet Therapy

• Continue DAPT (aspirin + ticagrelor) for 12 months post-MINOCA unless bleeding risk clearly outweighs ischemic benefit 4
• The recommended maintenance dose of aspirin with ticagrelor is 81 mg daily 4
• After successful endoscopic hemostasis, immediate resumption of antiplatelet therapy with PPI is recommended to prevent further ischemic events 5

Risk Stratification Considerations

High-Risk Features Requiring Cardiology Consultation

• Consult cardiology before holding ticagrelor >24-48 hours in this patient within 3 days of MINOCA 1
• Do not use heparin bridging while ticagrelor is held, as this increases bleeding without reducing thrombotic risk 1
• Patients within 2 weeks of acute coronary syndrome have the highest risk of stent thrombosis or recurrent MI if antiplatelet therapy is interrupted 1

Bleeding Risk Factors Present

• Advanced age (elderly) is an independent risk factor for major bleeding (OR increased significantly in patients >80 years) 4, 3
• Triple antithrombotic therapy (aspirin + ticagrelor + enoxaparin) carries 2.7% risk of GI bleeding 3
• Cardiogenic shock, if present, increases bleeding risk 21-fold 3

Critical Pitfalls to Avoid

• Do not stop both antiplatelet agents simultaneously, as median time to coronary thrombosis is only 7 days with both drugs withheld versus 122 days with only one withheld 4
• Do not transfuse platelets for ticagrelor-related bleeding, as the drug remains active in circulation and will inhibit transfused platelets 1
• Do not normalize INR/coagulation parameters before endoscopy in stable patients, as this delays definitive therapy without improving outcomes 4
• Do not use omeprazole or esomeprazole if clopidogrel is considered as alternative, due to CYP2C19 interaction; however, this is less relevant with ticagrelor 4

Escalation Criteria

Seek higher level care if: 1

• Bleeding continues despite endoscopic intervention and >2 hours of medical management
• Hemodynamic instability develops (hypotension, tachycardia)
• Transfusion requirement exceeds 2 units packed red blood cells
• Severe baseline anemia or symptoms of anemia develop