SHM Converge Scientific Abstract ePoster Gallery-Trapped Between Bleeding and Clotting: An Unresolvable Management Conflict in a Heyde Syndrome Patient

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This case describes an 81-year-old woman with severe, non-intervenable aortic stenosis, chronic iron-deficiency anemia from small-bowel AVMs, paroxysmal atrial fibrillation, and coronary artery disease previously treated with dual antiplatelet therapy. Her severe aortic stenosis likely caused Heyde’s syndrome, leading to acquired von Willebrand deficiency and recurrent gastrointestinal bleeding. She presented with confusion and hypoxia, and her hemoglobin was critically low at 4.9 g/dL. After transfusion, her symptoms improved temporarily.<br /><br />Because of her high bleeding risk, anticoagulation and aspirin were held. Shortly afterward, she developed word-finding difficulty, and MRI showed an acute left temporal ischemic infarct with a smaller subacute infarct. This created a major management conflict: standard stroke prevention and atrial fibrillation treatment increased the risk of further bleeding, while withholding therapy increased the risk of thrombosis and stroke.<br /><br />A multidisciplinary discussion led to cautious resumption of aspirin 81 mg daily, while clopidogrel and anticoagulation remained withheld. Neurology advised against more aggressive antithrombotic therapy because of her severe bleeding risk and ongoing aortic stenosis. Her aphasia improved with therapy, and she was discharged to short-term rehabilitation with stable hemoglobin.<br /><br />The case highlights the difficulty of managing patients with competing thrombotic and hemorrhagic risks, especially when guideline-directed therapies conflict. It emphasizes the importance of shared decision-making, goals-of-care discussions, and palliative approaches when recurrent hospitalizations and irreversible disease make standard treatment choices unsafe or impractical.

Asset Subtitle

Rakan Al-Ahmad

Meta Tag

Author List Ayobamidele Balogun, Bassil Akach, Damon Thompson, Joseph Fares, Lincy Philip, Maria Oliveira Souder, Michael Farid, Neel Patel, Rakan Al-Ahmad, Shruti Shah, Sri Harshini Gandhamaneni, Vinuri U. Goonesinghe

Category Clinical Vignettes

Concept Heyde Syndrome

Concept Aortic Stenosis

Concept Acquired von Willebrand Syndrome

Concept Angiodysplasia

Concept Gastrointestinal Bleeding

Distinguished Non-Finalist

Presenter Organization Inspira Medical Center

Presenting Author Rakan Al-Ahmad

Track Adult

Keywords

aortic stenosis

Heyde syndrome

gastrointestinal bleeding

atrial fibrillation

ischemic stroke

von Willebrand deficiency

iron-deficiency anemia

antiplatelet therapy

multidisciplinary management

shared decision-making

Heyde Syndrome

Aortic Stenosis

Acquired von Willebrand Syndrome

Angiodysplasia

Gastrointestinal Bleeding