Abstract
Managing acute coronary syndrome (ACS) in patients with a recent history of gastrointestinal bleeding presents a unique and challenging clinical dilemma, necessitating a careful balance between minimizing ischemic risk and avoiding potentially life-threatening rebleeding. Standard treatment for ACS typically involves dual antiplatelet therapy (DAPT) to prevent recurrent thrombotic events. However, in patients with recent gastrointestinal hemorrhage or significant anemia, these therapies may substantially increase the risk of life-threatening bleeding, complicating the decision-making process and often leading to conservative management strategies. In this case, we describe the presentation and management of an 80-year-old female with a history of Klatskin tumor resection, duodenal ulcer, and recurrent gastrointestinal bleeding who was admitted with symptoms suggestive of ACS. An electrocardiogram (EKG) revealed ST elevation in anterolateral leads, raising concerns for an acute myocardial infarction (MI). However, given her critically low hemoglobin (5.7 g/dL) and recent history of gastrointestinal hemorrhage, the decision was made to forgo aggressive interventions such as percutaneous coronary intervention (PCI) and DAPT. A conservative approach, including aspirin monotherapy and supportive care, was prioritized due to the high risk of rebleeding. Despite initial stabilization with transfusions, the patient later developed hemodynamic instability and was found to have a large ventricular septal defect (VSD) on echocardiography, ultimately leading to her demise. This case underscores the complexities of managing ACS in patients with severe anemia and recent gastrointestinal bleeding, where standard ACS protocols may be contraindicated. It highlights the importance of individualized, multidisciplinary treatment strategies and shared decision-making with patients and families to optimize care while aligning with the patient's overall health goals. In high-risk cases like this, a conservative approach may be warranted, even when it conflicts with traditional aggressive treatment pathways. The lessons learned from this case reinforce the need for flexibility and critical thinking in navigating the delicate balance between preventing ischemic complications and avoiding catastrophic bleeding in vulnerable patients.