Staged Antithrombotic Reinitiation After STEMI Complicated by LV Thrombus and Intracerebral Hemorrhage

Q4 Medicine

JACC. Case reports Pub Date : 2026-10-21 Epub Date: 2026-08-20 DOI:10.1016/j.jaccas.2026.109886

Slake Mokrytzki MBBS, Anne Yan Ting Chua MBBS, Alison Thompson MD, Miguel Mesarina DO, John F. Setaro MD

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Abstract

Background

Left ventricular thrombus after anterior ST-segment elevation myocardial infarction requires anticoagulation, and recent stenting requires dual antiplatelet therapy, but no guideline addresses antithrombotic sequencing when intracerebral hemorrhage complicates both.

Case Summary

A 63-year-old woman developed an apical left ventricular thrombus after left anterior descending artery percutaneous coronary intervention for late anterior ST-segment elevation myocardial infarction, then a left temporal intracerebral hemorrhage on day 2 while receiving aspirin, ticagrelor, and heparin. Declining ejection fraction and enlarging thrombi prompted staged reinitiation: cangrelor, clopidogrel, unfractionated heparin, then apixaban after serial neuroimaging confirmed stability.

Why Beyond the Guidelines

No guideline addresses the timing, sequence, or agent selection when these 3 indications converge.

Discussion

Staged reinitiation with short-acting and reversible agents may allow antithrombotic escalation guided by serial neuroimaging stability.

Take-Home Message

When competing thrombotic and hemorrhagic risks fall outside guideline pathways, antithrombotic therapy can be reintroduced in reassessable steps, starting with short-acting agents, guided by serial neuroimaging.

查看原文本刊更多论文

STEMI合并左室血栓和脑出血后分期抗血栓再启动。

背景：前st段抬高型心肌梗死后的左室血栓需要抗凝治疗，近期支架植入需要双重抗血小板治疗，但没有指南说明脑出血合并两种治疗时的抗血小板测序。病例总结：一名63岁女性因晚期前st段抬高型心肌梗死接受左前降支经皮冠状动脉介入治疗后出现左心室根尖血栓，在接受阿司匹林、替格瑞洛和肝素治疗的第2天出现左颞叶脑出血。射血分数下降和血栓增大提示分阶段重新启动：康格瑞、氯吡格雷、未分级肝素，在一系列神经影像学证实稳定后，再使用阿哌沙班。为什么超出指南：没有指南说明这3种适应症汇合时的时间、顺序或药物选择。讨论：分阶段重新启动短效和可逆的药物可能允许抗血栓增强指导下的一系列神经影像学稳定性。关键信息：当相互竞争的血栓和出血风险超出指南范围时，抗血栓治疗可以在可重新评估的步骤中重新引入，从短效药物开始，在连续神经成像的指导下。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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