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Updated: Aug 21, 2026

Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Staged Antithrombotic Reinitiation After STEMI Complicated by LV Thrombus and Intracerebral Hemorrhage
Slake Mokrytzki1, Anne Yan Ting Chua1, Alison Thompson1
1Greenwich Hospital, Greenwich, Connecticut, USA; Yale School of Medicine, New Haven, Connecticut, USA.
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.
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