Balancing Bleeding and Ischemic Risk: Dual Antiplatelet Therapy in a 90-Year-Old Man With Myocardial Infarction and Gastrointestinal Bleeding.

BACKGROUND Management of myocardial infarction (MI) in a patient with gastrointestinal (GI) bleeding presents a clinical challenge with competing ischemic and bleeding risks. Distinction of type 1 MI from type 2 MI is particularly important when planning antiplatelet therapy. CASE REPORT A 90-year-old man presented with MI, severe acute-on-chronic anemia, and active GI bleeding. The etiology of his MI was unclear in the setting of severe coronary artery disease, although type 2 MI was favored when his chest pain resolved with blood transfusions. After treatment of his bleeding angiodysplasias, dual antiplatelet therapy (DAPT) was attempted but discontinued due to recurrent bleeding. Ischemic heart disease was managed conservatively with antiplatelet monotherapy, which was subsequently withheld after shared decision making with the patient. At the 3-month follow-up, his symptoms were controlled with optimized antianginal therapy, although he required rehospitalization for recurrent GI bleeding that was treated endoscopically. CONCLUSIONS This case highlights the nuances of treating acute ischemic heart disease and the complexity of decision making regarding DAPT in patients with high GI bleeding risk. The risks and benefits of DAPT should be continually assessed in patients who exhibit bleeding or have a risk of bleeding onset. If antiplatelet monotherapy is considered due to GI bleeding, P2Y12 inhibitors such as clopidogrel are preferable. The outcome of the present case supports individualized treatment and may have broader implications for older patients with coexisting GI bleeding and coronary artery disease.