In a patient with ST‑segment‑elevation myocardial infarction (STEMI) who is actively bleeding from the gastrointestinal (GI) tract, what is the preferred reperfusion strategy and what specific management steps should be taken?

Reperfusion Strategy for STEMI with Active GI Bleeding

In a STEMI patient with ongoing GI bleeding, primary PCI is the strongly preferred reperfusion strategy because fibrinolytic therapy is absolutely contraindicated due to active bleeding, and PCI should be performed regardless of time delay from symptom onset. 1

Why Primary PCI is Mandatory

Active GI bleeding represents an absolute contraindication to fibrinolytic therapy, eliminating this option entirely from consideration. 2 The guidelines explicitly state that primary PCI should be performed in patients with STEMI and contraindications to fibrinolytic therapy, irrespective of time delay from first medical contact. 1

• Primary PCI avoids the hemorrhagic risk inherent to thrombolytic agents while still providing superior reperfusion compared to medical therapy alone. 3
• Even with anticipated delays exceeding 120 minutes, PCI remains the only viable reperfusion option when fibrinolysis is contraindicated. 1
• The mortality benefit of reperfusion therapy outweighs procedural bleeding risks in this scenario, as untreated STEMI carries substantially higher mortality than the bleeding complications of PCI. 1

Specific Management Steps

Immediate Actions (Within 10 Minutes)

• Administer aspirin 150-325 mg orally or 250-500 mg IV immediately despite the GI bleeding—the mortality benefit in STEMI outweighs bleeding risk, and aspirin is essential for PCI success. 1, 3, 4
• Obtain 12-lead ECG within 10 minutes and activate the catheterization laboratory immediately. 1, 3
• Initiate continuous ECG monitoring with defibrillator capacity. 1
• Avoid routine oxygen unless oxygen saturation is <90%. 1, 4

Antithrombotic Strategy Modifications

The key challenge is balancing thrombotic risk from STEMI against hemorrhagic risk from active GI bleeding:

• Defer P2Y12 inhibitor loading until after diagnostic angiography when the coronary anatomy is known and PCI is definitively indicated—this minimizes unnecessary bleeding risk if PCI is not needed. 1, 3
• Use unfractionated heparin as the anticoagulant (70-100 U/kg IV bolus, reduced from the standard 100 U/kg) because it has the shortest half-life and can be reversed with protamine if bleeding worsens. 1, 3
• Avoid bivalirudin and enoxaparin in this setting—UFH's reversibility makes it safer with active bleeding. 1
• Absolutely avoid fondaparinux, which is already contraindicated for primary PCI. 1, 3

During PCI

• Use radial artery access exclusively—this dramatically reduces access-site bleeding complications compared to femoral access. 3, 4
• Implant drug-eluting stents as the default strategy. 3, 4
• Avoid routine thrombus aspiration—this is contraindicated and provides no benefit. 3, 4
• Minimize contrast volume to reduce risk of contrast-induced nephropathy, which would complicate management of both bleeding and anticoagulation. 3

Post-PCI Antiplatelet Management

This is where the greatest clinical judgment is required:

• Administer a potent P2Y12 inhibitor (prasugrel or ticagrelor) immediately after successful PCI despite ongoing bleeding—the stent thrombosis risk in the first 24-48 hours is catastrophic and outweighs GI bleeding risk. 1, 3, 4
• Consider reduced-dose prasugrel (5 mg daily instead of 10 mg) or standard-dose ticagrelor (90 mg twice daily) based on bleeding severity and patient factors. 1
• Initiate proton pump inhibitor therapy immediately to reduce GI bleeding risk from dual antiplatelet therapy. 3

Concurrent GI Management

• Coordinate immediately with gastroenterology for urgent upper endoscopy once the patient is stabilized post-PCI—ideally within 12-24 hours. 3
• Transfuse packed red blood cells to maintain hemoglobin >7-8 g/dL, balancing oxygen-carrying capacity needs against volume overload risk. 3
• Monitor hemoglobin every 4-6 hours in the first 24 hours post-PCI. 3
• Avoid NSAIDs absolutely for post-infarction pericarditis management if it develops. 3

Critical Pitfalls to Avoid

Do not delay PCI to "stabilize" the GI bleeding first—the STEMI mortality risk exceeds GI bleeding mortality risk, and guidelines explicitly state that cardiogenic shock or acute severe heart failure mandate PCI irrespective of time delay. 1

Do not withhold aspirin or P2Y12 inhibitors due to bleeding concerns—stent thrombosis is immediately fatal, while GI bleeding is manageable with transfusion and endoscopic intervention. 1, 3

Do not use fibrinolysis under any circumstances—active bleeding is an absolute contraindication, and administering lytics would likely prove fatal. 2

Do not use femoral access—radial access is mandatory to minimize bleeding complications. 3, 4

Time-Critical Transfer Protocol

• Transfer directly to the catheterization laboratory, bypassing the emergency department entirely. 1, 3
• PCI-capable centers must perform the procedure without delay, even if this occurs at 2 AM—the 24/7 availability is specifically designed for these high-risk scenarios. 1
• Every 30-minute delay increases mortality, so the bleeding should not delay transfer or PCI. 2

Post-Discharge Considerations

• Continue dual antiplatelet therapy for 12 months unless life-threatening bleeding recurs—premature discontinuation dramatically increases stent thrombosis and mortality risk. 1, 3, 4
• Maintain PPI therapy throughout the DAPT duration to minimize recurrent GI bleeding. 3
• Arrange close gastroenterology follow-up to address the underlying cause of GI bleeding and prevent recurrence. 3