Anticoagulation Management in an Older Patient with Extensive Cardiac Medical History and Recurrent Gastrointestinal Bleeding—Case Report

Anticoagulation therapy prevents thromboembolic events in higher risk patients. However, gastrointestinal bleeding occurs in 5–15% of patients receiving long-term anticoagulation. Management of anticoagulation can be difficult in patients with multiple indications for this therapy. Despite significant benefits of anticoagulants, a retrospective study at a stroke unit in Italy found that only 21.9% of patients hospitalized for a stroke or transient ischemic attack received appropriate anticoagulant therapy before the adverse event. A retrospective analysis of the National Cardiovascular Data PINNACLE Registry found that the rate of overall anticoagulant use in nonvalvular atrial fibrillation patients was 60.7% and that of any direct oral anticoagulant use was 25.8% towards the end of the study period of interest. A 76-year-old female with chronic persistent atrial fibrillation, recurrent gastrointestinal bleeding, recent argon plasma photocoagulation of a colonic arteriovenous malformation, and history of transcatheter mitral valve replacement (TMVR) in a bioprosthetic mitral valve presented with acute gastrointestinal bleeding. Her anticoagulation regimen was reassessed. As the patient’s CHA2DS2VASc thromboembolic risk was greater than her HASBLED bleeding risk, a direct oral anticoagulant was commenced to prevent thromboembolic events. Since there are no guidelines for post-TMVR anticoagulation, the patient requires strict follow-up to detect early signs of valve dysfunction or thrombosis for the appropriate management of anticoagulation therapy. Clinicians must be educated on the importance and methods of evaluating the need for anticoagulation therapy. Our case is unique for the patient’s extensive cardiac history demonstrating multiple indications for anticoagulation despite the concern for gastrointestinal bleeding. Several medical specialties may be involved in discussions of anticoagulation use depending on the patient’s presentation and risk factors. Patients must also be engaged in the decision-making process. Providers must educate patients on the indications, side effects, and duration of their anticoagulant therapy. Lastly, more studies are needed to develop guidelines for post-TMVR anticoagulation.