Case report: 65-years-old man has been admitted to hospital because of spontaneous retroperitoneal hematoma. Medical history and concomitant disease: 1996 thyroidectomy for papillary carcinoma, arterial hypertension for more than 10 years and chronic obstructive pulmonary disease. Patient had acute ST segment elevation myocardial infarction (STEMI) when percutaneous coronary intervention on D1 using right transradial approach was done. Because of pulmonary edema during acute phase, he needed mechanical respiratory support and application of bronchodilatatory and corticosteroid therapy. Echocardiography showed reduced systolic function (EF 30%). Patient was discharge from hospital at the 6th day with prescription of ticagrelor 90 mg bid, nebivolol 1,25 mg, aspirin 100 mg, furosemid 125 mg, spironolactone 50 mg, valsartan 160 mg bid, amiodarone 200 mg, atorvastatin 80 mg, pantoprazole 40 mg, methylprednisolone 16 mg, levothyroxine 150 µg and tiotropium bromide 18 µg. 22 days after STEMI he was admitted again because of dizziness and lightheadedness with drop of hemoglobin levels from 136 to 82g/L and high potassium levels. Prothrombin time and APPT was normal. Multiple hematomas on the legs and lumbar region were noticed with no anamnesis of trauma. Multislice computed tomography (MSCT) showed retroperitoneal hematoma on the left side from left kidney to the left inguinal region 7.5 x 10.5 cm, 22 cm in length. Ticagrelor and aspirin were stopped. Platelet function analysis (by Multiplate^® analyzer) showed extremely depressed aggregation with aspirin (less than 100 AUmin) and with ticlopidin (234 AUmin). Two dose of concentrated erythrocyte were applied. Hemoglobin levels stayed stabile and control MSCT showed no progression of hematoma 7 days after second admission.

Discussion: Major bleeding after myocardial infarction portends a poor outcome. In the PLATO trial ticagrelor compared with clopidogrel was associated with similar total major bleeding but increased non-CABG and non-procedure-related major bleeding, primarily after 30 days on study drug treatment. Fatal bleeding was low and did not differ between groups. There remains potential concern about bleeding in a “real world” population compromising more high risk patients; particularly more elderly and female, than those in PLATO. (1)

Conclusion: A balance is required between potency of platelet inhibition and risk of bleeding.