Case Presentation: Heyde’s syndrome—marked by severe aortic stenosis (AS), angiodysplasia, and acquired von Willebrand syndrome—predisposes patients to recurrent GI bleeding and creates major conflicts in cardiovascular management. We present an 81-year-old woman with severe, non-intervenable AS; chronic iron-deficiency anemia; known small-bowel AVMs; paroxysmal atrial fibrillation (AF) not anticoagulated due to bleeding; and CAD previously on DAPT. She was found confused and hypoxic during a wellness check. In the ED, she was oriented only to self with hemoglobin 4.9 g/dL. CT head was negative. Family noted similar episodes of acute confusion every 2–3 months, coinciding with anemia.After 3 units PRBCs, hemoglobin improved to ~9.5 g/dL. Iron studies confirmed iron deficiency. DAPT was held. Although mentation improved, she developed new word-finding difficulty. MRI revealed an acute left temporal infarct and a smaller subacute infarct. CTA head/neck was normal. Neurology advised against anticoagulation or DAPT given her high bleeding risk and severe AS.Repeat capsule endoscopy found a single non-bleeding small-bowel AVM; EGD was negative. After multidisciplinary discussion, aspirin 81 mg daily was cautiously restarted, while clopidogrel and anticoagulation remained held. Her aphasia improved with therapy, and she was discharged to short-term rehab with stable hemoglobin.This case highlights a therapeutic impasse: aortic valve replacement—often curative for Heyde’s syndrome—was not feasible, yet AF, CAD, and acute ischemic stroke typically require anticoagulation or DAPT. Her recurrent profound anemia likely drove episodic encephalopathy and increased vulnerability to cerebral ischemia. Management required individualized risk-benefit assessment, multidisciplinary collaboration, and incorporation of palliative-care principles when guideline-directed therapy was unsafe.
Discussion: This case illustrates the tension between thrombotic and hemorrhagic risks in an older adult with:• Severe AS–associated GI bleeding (Heyde’s syndrome)• Recurrent AVM-related iron-deficiency anemia• AF with high CHA₂DS₂-VASc score• Acute ischemic stroke• CAD previously requiring DAPTHer inoperable AS sustained her vWF deficiency and bleeding tendency, directly opposing the need for anticoagulation or antiplatelet therapy. Her acute confusion episodes underscore the importance of recognizing anemia-induced encephalopathy. Managing these competing risks required deviation from standard evidence-based pathways in favor of individualized, safety-focused decision-making.
Conclusions: This case exemplifies the complexity of managing simultaneous bleeding and thrombotic risks in older adults when definitive interventions are not feasible. It reinforces the importance of personalized care, early multidisciplinary involvement, and adapting guidelines to real-world clinical constraints.