Retroperitoneal Bleed with Ticagrelor Administration Followi
Introduction:
In ST-elevation myocardial infarction, complete occlusion of culprit coronary artery occurs in majority of patients. It is important that the artery is opened as soon as possible to restore blood to the jeopardized myocardium and direct coronary intervention is considered the appropriate care. In a setting of primary percutaneous coronary intervention (PCI),
dual antiplatelet therapy with prasugrel or ticagrelor or clopidogrel,are recommended in addition to Aspirin at presentation. Available recommendations indicate administration of clopidogrel only after fibrinolytic therapy, due to concern that ticagrelor is more potent and combining
such a potent antiplatelet agent with fibrinolytic therapy might increase the risk of bleeding. An environment of increased tendency to bleed is created when fibrinolytic therapy has to be carried out instead of primary PCI. We report significant retroperitoneal bleed requiring multiple blood transfusions when ticagrelor is followed by fibrionolytic therapy in
a setting of acute ST elevation myocardial infarction.

Case:
A 50-year male presented with severe central, retrosternal chest pain of 30 minutes duration. ECG showed acute anterior ST-elevation myocardial infarction. He received Aspirin 325 mg with Ticagrelor 180 mg with a plan for primary PCI. He also received Tab. Atorvastatin 80 mg. After 5 minutes after administering dual antiplatelet therapy, patient changed
his preference, refused primary PCI and instead opted for fibrinolytic therapy. After explaining the risks and benefits of fibrinolytic therapy, he was administered Reteplase 10 units Intravenous bolus (over 2 minutes), followed by second dose after 30 minutes-(for total cumulative dose of 20 units). A good resolution of ST-elevation on ECG indicated benefit with reperfusion. After 2 hours patient developed hypotension
(90/70mm Hg) and he complained of severe backache, abdominal and bilateral flank pain. There was a significant drop of hemoglobin by more than 5g/dL. Prothrombin time increased from 11.5 seconds to 22.0 seconds....

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