Thanks for all the great replies from great Professors , I would like to give more information about that real life challenging case. 63 years old lady suffering of DM,HTN and ESRD on regular hemodialysis. She had a coronary stent(DES) 7 months before hospital admission.She presented to ER suffering of heamatemsis and melena and upper endoscopy done revealed reflux esophagitis.During hospital stay ECG showed depressed ST segment on v1-v3 leads and her serial troponin I showed rising levels but there was no chest pain. She was receiving aspirin , clopidogrel, statin , ACEi , B blocker and insulin. Upon examination she was HD stable , in sinus rhythm, with no evidence of heart failure or murmurs.
After stoppage of bleeding GRACE /Crusade scores were measured to assess risk of bleeding and that of cardiovascular events.She has 30% risk of death in 6 months on GRACE score and and risk of 30% of in hospital major bleeding. Conservative medical or early invasive therapy?
1)What do you think is the best management in this patient...keeping in mind that under treatment increases risk of death and cardiac complications with a probably stenosed coronary stent while aggressive treatment is associated with risk of death from significant bleeding.
2)Are there any guidelines or a consensus regarding management of such challenging cases ?
3)If you choose the medical therapy when can we start anticoagulants and platelets after stoppage of bleeding?
Waiting to hear valuable inputs from my professors and colleagues....Thank you
Need more information. How much bleeding is there and what is the possible source? Has the NSTEMI been self limited or are there ongoing cardiac issues?
Management will need to be medical in the first instance untill it can be ascertained what else needs to be done to address the GI bleeding.
GI bleeding is life threatening especially in a patient requiring anticoagulation for hemodialysis session, hence endoscopy is mandatory
I tend to agree with Deborah on this, that the more conservative (non-lytic) medical treatment is suggested here due to GI Bleeding, as a more invasive procedural treatment is apt to increase risk of further bleeding... ASA may be contraindicated, but beta blockade and ACE could be administered...
99% agree with my colleagues. First endoscopic study to filiate origin of the bleeding, then is mandatory to do a programmed coronary angiography. Once you know the etiology of the bleeding and its possible solution you can decide an antiagregation therapy (if possible, perhaps only LMWH?). Regards
Hello
in addition , i suggest CVVHD instead of IHD due to decrease cardiac injury .
This patient should undergo coronary artery angiography to deternine whether there is a correctable lesion or not. The aspirin may need to be ceased if ongoing gastrointestinal haemorrhage is an issue.