Management of ST-elevation myocardial infarction in the setting of anterior epistaxis: focused on antiplatelet and antithrombotic therapies

Background: Antiplatelet and antithrombotic therapies are part of standard core treatments for ST-elevation myocardial infarction (STEMI). Effectiveness of these therapies, however, is often offset by the resultant hemorrhagic complications, which in turn possess significantly worse prognosis. Acute myocardial infarction (AMI) accompanied by acute bleeding, such as anterior epistaxis, is common and arise potential dilemma in deciding appropriate management as a standard medical strategy that may put patients in immediate threat as it increases the ongoing bleeding event.

Case description: A 46-year-old male patient with late-onset infero-posterolateral STEMI and anterior epistaxis was admitted to the emergency ward of Mangusada Regional Hospital. The patient had long-standing history of uncontrolled hypertension and previously been treated with tranexamic acid to stop nasal bleeding. Neither percutaneous coronary intervention nor fibrinolysis was performed due to financial issue, and patient only managed conservatively with adequate medications including dual antiplatelet with aspirin and clopidogrel and anticoagulant with unfractionated heparin. No active bleeding was observed during in-hospital treatment and the patient was then discharged after 8 days with complete improvement of symptoms and ST-segment elevation resolution.

Conclusion: This case report highlights the treatment strategy for patients with myocardial infarction in the setting of acute bleeding focusing on antiplatelet and anticoagulant therapies. We also discussed the potential association between tranexamic acid and arterial thromboembolic complication resulting in AMI.