Introduction: It is well known that oral anticoagula-tion associated with dual antiplatelet (triple therapy) is recommended by the current ESC guideline for patients with acute coronary syndromes or coronary interventions that present atrial fibrillation. However, the risk-benefit ratio (bleeding vs. ischemia) requires careful evaluation to determine the optimal therapy, especially in patients with an increased bleeding risk.

Case presentation: A 67-year-old male patient pre-sents with constricting, high intensity anterior chest pain, with a sudden onset one hour prior to the Emer-gency Department admission, accompanied by nausea, profuse sweating and extreme anxiety. The patient is known to have persistent atrial fibrillation for 2 years for which he was treated with oral antivitamin K an-ticoagulant (AVK). The AVK was stopped 2 months earlier in the context of an acute upper gastrointestinal bleeding (NSAID related gastric ulcer and coumarin overdose – INR 5.8 at that time). The samples for H. pylori were negative and the patient was undergoing treatment with proton pump inhibitors. At presentation, his general condition was altered, he had a normal blood pressure (130/90 mmHg), in-creased ventricular rate (120 bpm) and irregular heart sounds. The electrocardiogram revealed high-rate atri-al fibrillation and a ST segment elevation of 4 mm in V1-V4, based on which the diagnosis of acute anterior STEMI is established. His blood workup revealed signi-ficant dyslipidemia (total cholesterol 300 mg / dl, LDL 230 mg / dl) and impaired glucose tolerance (HbA1c 6.1%). The myocardial necrosis enzymes were normal limits at first determination (<3 hours after onset). Echocardiography showed anterior, lateral and apical wall hypokinesis and a left ventricle ejection fraction of 35-40%. The emergency coronary angiogram revealed a thrombotic occlusion of the proximal left anterior des-cending artery and was followed by PCI with a drug-eluting stent, with very good final result and TIMI3 flow. After the procedure the patient’s general state im-proved and the chest pain subsided. The ST segment elevation was reduced by more than 50% and negative T and Q waves in V1-V4 remained. The patient’s hos-pital stay was uneventful. He received dual antiplatelet therapy, low molecular weight heparin, a beta blocker, ACE inhibitor, MR antagonist and statin. Given the high CHA2DS2VASc score in this case (4), life-long oral anticoagulation is indicated. At the same time the patient has an increased hemorrhagic risk (recent GI bleed, coumarin overdosage, age). The combination of antiplatelet therapy (single, and more so dual), also in-dicated in this case, substantially increases the hemor-rhagic risk in combination with oral anticoagulation. Recent data revealed the safety of double-combination (P2Y12 inhibitor + non-AVK oral anticoagulant), with a low rate of major bleeding versus triple therapy (aspi-rin + P2Y12 + AVK inhibitor). Therefore, a combinati-on of clopidogrel 75 mg / day for 12 months associated with long-term apixaban therapy (5 mg x 2 / day) was indicated in this case.

The particularity of the case: The particularity of this case is the significant hemorrhagic risk in this patient with a recent GI bleed who requires long-term oral an-ticoagulation and presents with an acute myocardial infarction, with the need for potent and efficient anti-thrombotic therapy, but at the same time requiring the lowest possible bleeding risk.

Conclusions: This case draws our attention to the care-ful evaluation of the risk-benefit ratio in patients with an indication for antiplatelet therapy and long-term oral anticoagulation, recent data guiding the clinici-an in making an optimal decision for improving the patient’s prognosis.