Presyncope Unmasking a Massive Upper Gastrointestinal (GI) Bleed One Month After Multivessel Percutaneous Coronary Intervention (PCI) on Dual Antiplatelet Therapy.

Upper gastrointestinal (GI) bleeding is a life-threatening emergency that requires timely recognition, resuscitation, and carefully tailored transfusion strategies. Dual antiplatelet therapy (DAPT), while essential after percutaneous coronary intervention (PCI), substantially increases bleeding risk and creates a major therapeutic dilemma when severe bleeding occurs soon after stent placement. We report an 87-year-old man with hypertension, dyslipidemia, and ischemic heart disease who presented with presyncope and dizziness one month after multivessel PCI with four drug-eluting stents. He was on DAPT with aspirin and clopidogrel. Laboratory evaluation revealed severe anemia (hemoglobin (Hb) 5.3 g/dL), and he subsequently developed hematemesis and melena with hemodynamic compromise. Urgent endoscopy identified multiple large esophageal ulcers with active bleeding, which were successfully managed with adrenaline injection. Transfusion was guided by a restrictive strategy, targeting Hb 8-9 g/dL in view of his recent cardiac history. A multidisciplinary decision was made to de-escalate antiplatelet therapy to clopidogrel monotherapy while continuing high-dose proton pump inhibitor therapy. This case underscores the complexity of balancing thrombosis and bleeding risks in the immediate post-PCI period, highlighting the role of multidisciplinary coordination, restrictive transfusion thresholds, and timely endoscopic intervention.