Strobl Stefanie, Zuber-Jerger Ina
Klinik und Poliklinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Germany.
Med Klin (Munich). 2010 Apr;105(4):296-9. doi: 10.1007/s00063-010-1044-4.
A 73-year-old man with NSTEMI (non-ST segment elevation myocardial infarction) underwent coronary angiography and an in-stent restenosis and thrombosis in ramus circumflexus was found. A drug-eluting stent (DES) was implanted. 12 h after intervention during threefold platelet inhibition the patient presented a gastrointestinal bleeding with melena and the hemoglobin level dropped from 15.3 g/dl to 9.7 g/dl.
Blood tests revealed a considerable elevation of cardiac enzymes, troponin I, leukocytes and C-reactive protein but normal hemoglobin. In coronary angiography, the stent in ramus circumflexus was found to be occluded. Therefore, a percutaneous coronary intervention with implantation of a DES (Taxus) was performed. In gastroscopy, a 2.5-cm necrotic formation resembling a tumor with an oozing bleeding was identified. The bleeding was stopped after injection of adrenaline. Histological evaluation showed no criteria of malignancy.
With high-dose proton pump blocker therapy, calculated Helicobacter pylori eradication with amoxicillin and clarithromycin, and cessation of NSAID (nonsteroidal anti-inflammatory drugs), the hemoglobin level was stable with 9.7 g/dl. No blood transfusion and no interruption of the dual platelet inhibition were necessary. In control gastroscopy, the initial endoscopically malignancy-suspicious formation presented as a small, superficial, healing ulcer.
Bleeding complications after stent implantation create a dilemma situation. The risk of a hemorrhagic shock by continuing platelet inhibition therapy and the risk of an acute stent thrombosis with interruption of the platelet inhibition should be carefully calculated considering individual facts and the guidelines.
一名73岁患有非ST段抬高型心肌梗死（NSTEMI）的男性接受了冠状动脉造影，发现其回旋支存在支架内再狭窄及血栓形成。随后植入了药物洗脱支架（DES）。介入治疗12小时后，在三联抗血小板抑制治疗期间，患者出现了伴有黑便的胃肠道出血，血红蛋白水平从15.3 g/dl降至9.7 g/dl。
血液检查显示心肌酶、肌钙蛋白I、白细胞及C反应蛋白显著升高，但血红蛋白正常。冠状动脉造影显示回旋支支架闭塞。因此，进行了经皮冠状动脉介入治疗并植入了一枚DES（紫杉醇洗脱支架）。胃镜检查发现一个2.5厘米的坏死灶，类似肿瘤，有渗血，注射肾上腺素后出血停止。组织学评估未发现恶性肿瘤的特征。
采用大剂量质子泵阻滞剂治疗，联合阿莫西林和克拉霉素根除幽门螺杆菌，并停用非甾体抗炎药（NSAID），血红蛋白水平稳定在9.7 g/dl。无需输血，也无需中断双联抗血小板治疗。在胃镜复查中，最初内镜下怀疑为恶性的病灶呈现为一个小的、浅表的愈合性溃疡。
支架植入后的出血并发症会造成两难局面。应根据个体情况和指南仔细权衡继续进行血小板抑制治疗导致出血性休克的风险以及中断血小板抑制治疗引发急性支架血栓形成的风险。
