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Peer-reviewedCC BY-NC-ND 4.0JACC: Case Reports

Staged Antithrombotic Reinitiation After STEMI Complicated by LV Thrombus and Intracerebral Hemorrhage

  • Slake Mokrytzki, MBBS1
  • Anne Yan Ting Chua, MBBS1
  • Alison Thompson, MD1
  • Miguel Mesarina, DO1
  • John F. Setaro, MD1
  1. 1Greenwich Hospital, Greenwich, Connecticut, USA; Yale School of Medicine, New Haven, Connecticut, USA
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Abstract

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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Cite

BibTeXRIS
BibTeX
@article{slakemokrytzki2026staged,
  title = {{Staged Antithrombotic Reinitiation After STEMI Complicated by LV Thrombus and Intracerebral Hemorrhage}},
  author = {Slake Mokrytzki, MBBS and Anne Yan Ting Chua, MBBS and Alison Thompson, MD and Miguel Mesarina, DO and John F. Setaro, MD},
  journal = {JACC: Case Reports},
  year = {2026},
  month = aug,
  doi = {10.1016/j.jaccas.2026.109886},
  url = {https://doi.org/10.1016/j.jaccas.2026.109886},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Staged Antithrombotic Reinitiation After STEMI Complicated by LV Thrombus and Intracerebral Hemorrhage
AU  - Slake Mokrytzki, MBBS
AU  - Anne Yan Ting Chua, MBBS
AU  - Alison Thompson, MD
AU  - Miguel Mesarina, DO
AU  - John F. Setaro, MD
PY  - 2026
DA  - 2026/08/20
JO  - JACC: Case Reports
DO  - 10.1016/j.jaccas.2026.109886
UR  - https://doi.org/10.1016/j.jaccas.2026.109886
AB  - 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.
SN  - 2666-0849
ER  -