Aisya Ayu Shafira, Hanestya Oky Hermawan

Invasive Strategy of STEMI in Patients with TAVB, RBBB, and Dual High-Risk Profiles: Navigating the Challenges of Antithrombotic Therapy – A Case Report

Introduction

Invasive strategy of stemi in patients with tavb, rbbb, and dual high-risk profiles: navigating the challenges of antithrombotic therapy – a case report. Complex STEMI case in a patient with total AV block & RBBB highlights challenges in balancing antithrombotic therapy with reperfusion, leading to severe GI bleeding post-PCI.

Abstract

Background: It is imperative to diagnose and treat acute coronary occlusion as soon as possible, especially in patients with complicated conduction anomalies. Although electrocardiography (ECG) is still the gold standard for diagnosis, it has drawbacks, particularly when conduction abnormalities such as bundle branch block are present. Case Summary: In this case study, a 60-year-old woman with cardiovascular risk factors and type 2 diabetes had an anteroseptal STEMI that was worsened by RBBB and total AV block. The patient's recovery was complicated by extensive gastrointestinal bleeding after a successful percutaneous coronary intervention (PCI) and the implantation of a stent in the left anterior descending artery. Conclusion: In addition to highlighting the difficulties of striking a balance between dual antiplatelet therapy (DAPT) and reperfusion strategies in a high bleeding risk setting, this also highlights the management of a high-risk STEMI patient with total atrioventricular (AV) block, right bundle branch block (RBBB), and severe gastrointestinal complications. -- Highlights: 1. This case illustrates the complex management of STEMI with total AV block and right bundle branch block, where urgent PCI and temporary pacing achieved rapid hemodynamic stabilization. 2. Post-PCI gastrointestinal bleeding under dual antiplatelet therapy highlights the need for individualized antithrombotic strategies and vigilant post-discharge monitoring in high-risk patients.

Review

This case report, "Invasive Strategy of STEMI in Patients with TAVB, RBBB, and Dual High-Risk Profiles: Navigating the Challenges of Antithrombotic Therapy," presents a compelling and instructive clinical scenario. The authors effectively highlight the diagnostic and therapeutic complexities encountered in a 60-year-old patient with an anteroseptal STEMI complicated by the presence of total AV block and a pre-existing RBBB. This unusual confluence of severe conduction abnormalities alongside acute coronary occlusion significantly obscures the typical ECG presentation of STEMI and necessitates rapid, nuanced decision-making regarding reperfusion and rhythm management. The successful PCI and subsequent hemodynamic stabilization underscore the critical importance of invasive strategies even in such challenging settings. A major strength of this report lies in its detailed exposition of the subsequent management challenge: balancing effective antithrombotic therapy with an inherent high bleeding risk. The development of extensive gastrointestinal bleeding post-PCI under dual antiplatelet therapy (DAPT) serves as a potent reminder of the narrow therapeutic window in these vulnerable patients. This complication forces clinicians to meticulously weigh the benefits of preventing stent thrombosis against the risks of major hemorrhage, particularly in individuals with multiple predisposing factors. The case powerfully illustrates the need for individualized antithrombotic strategies and proactive risk assessment, especially when managing high-risk patients with pre-existing comorbidities and complex cardiac presentations. While the report clearly outlines the difficulties, a more explicit discussion of the specific considerations and decision-making processes regarding DAPT modification or alternative strategies post-bleeding would enhance its educational value further. For instance, did the authors consider proton pump inhibitor co-prescription, or specific DAPT components known for lower bleeding risk, or a shortened DAPT duration? Nevertheless, the case successfully achieves its objective of underscoring the delicate balance required in managing such high-risk patients. It is a valuable contribution to the literature, offering practical insights into the clinical navigation of patients with complex STEMI, multiple conduction defects, and life-threatening bleeding complications, thereby reinforcing the need for vigilant post-discharge monitoring and tailored therapeutic approaches.

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