Primary Percutaneous Coronary Intervention in Patients With ST-Segment-Elevation Myocardial Infarction and Concurrent Active Gastrointestinal Bleeding.

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Reperfusion therapy via percutaneous coronary intervention (PCI) as the preferred method of treatment for an acute ST-segment–elevation myocardial infarction (STEMI) requires the use of potent antiplatelet agents (eg, aspirin, P2Y12 inhibitors, and GPIIb/IIIa antagonists) and anticoagulant therapies, including heparin or bivalirudin,1 both of which have potential risk of bleeding. An increased bleeding risk in some patients with STEMI makes the use of antiplatelet/anticoagulant agents a relative or absolute contraindication to PCI. Acute gastrointestinal bleed (GIB) in the acute coronary syndrome setting is a particularly vexing situation requiring the balancing of risk/benefit for each condition and a resultant high-risk decision for the treatment of either condition. Clinically significant GIB may present concomitantly in an estimated 1.3% of cases of acute coronary syndrome, based on the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial.2 Guidance concerning optimal management and ensuing strategies in patients with STEMI and contraindications to antiplatelet/antithrombotic agents, specifically with respect to patients who present with parallel and active GIB from literature is scant at best. In this report, we discuss the challenges of managing competing treatment strategies in a patient who presents with concurrent STEMI and acute active GIB. ### Case Presentation A 68-year-old woman presented to the emergency room with severe nausea and vomiting, accompanied by extreme fatigue, dizziness, and light headedness. The symptoms began 7 hours earlier and had been gradually increasing in severity. Vomitus was nonbilious, nonbloody, without coffee ground appearance. She denied chest pain or pressure, palpitations, orthopnea, and reported only mild dyspnea. Two weeks before presentation, the patient described having melena. Her primary care physician documented hemoglobin of 5.1 g/dL. However, the patient refused a blood transfusion and preferred therapy with only iron infusion. An esophagogastroduodenoscopy revealed no abnormalities. Colonoscopic imaging was inconclusive because of inadequate gastrointestinal preparation. In 2011, the patient had PCI …