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

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.