Acquired Hemophilia A During Prasugrel Therapy After Recurrent Acute Coronary Syndrome

Acquired hemophilia A (AHA), a rare autoimmune bleeding disorder caused by factor VIII inhibitors, may be overlooked in patients receiving antiplatelet therapies.

A 60-year-old woman underwent percutaneous coronary intervention for non-ST-segment elevation myocardial infarction, receiving aspirin and prasugrel. After recurrent unstable angina, repeat percutaneous coronary intervention was performed, and dual antiplatelet therapy (DAPT) was resumed. One month later, she developed diffuse ecchymoses and progressive anemia. Investigations indicated AHA with isolated activated partial thromboplastin time (APTT) prolongation, reduced factor VIII activity, and factor VIII inhibitor positivity. DAPT was discontinued, and high-dose corticosteroid was initiated, causing complete remission; aspirin monotherapy was restarted. Unstable angina recurred, and coronary artery bypass grafting was performed.

Unexplained bleeding with isolated APTT prolongation on DAPT should prompt evaluation for AHA and early hematology consultation.

Recognize AHA early; stop DAPT when safe, and favor revascularization strategies that minimize prolonged DAPT.