A 44‐year‐old woman with a history of hereditary hemorrhagic telangiectasia presented to the ED with complaints of epistaxis, coffee‐ground emesis, dyspnea, and burning chest pain. In the ED, she was mildly hypotensive but otherwise stable. Her hemoglobin was 6.0, and she was admitted to the head and neck surgery service for transfusion and laser ablation of nasal telangiectasias. As her dyspnea and chest pain did not resolve with blood transfusions, she was transferred to the medical service for evaluation. A jejunal telangiectasia was found on enteroscopy and treated with bipolar coagulation. A CT angiogram of the chest found no pulmonary telangiectasias, but noted multiple bilateral pulmonary emboli. Duplex Doppler imaging of the lower extremities was negative for deep vein thrombus. Further discussions with the patient and her primary physician revealed that: (1) the patient continued to use tobacco, and (2) she had previously been given a trial of oral estrogen to decrease bleeding from her telangiectasias. While on estrogen, she had noted a feeling of “bloating” in her legs and abdomen and had discontinued the therapy. The patient was discharged without anticoagulation and with recommendations to abstain from tobacco and to avoid the use of estrogen therapies.
Hospitalists are often the first to identify prothrombotic states and their sequelae. Given the mortality associated with untreated pulmonary emboli, anticoagulation is strongly indicated once the diagnosis is made. The classic if oversimplified teaching is that the next embolus must be prevented. In the presence of bleeding, anticoagulation is often delayed but only until hemostasis is achieved. This patient's lifelong bleeding risk made anticoagulation dangerous at any time. The history of tobacco and estrogen use and the absence of additional clot burden suggested that the prothrombotic state may have already resolved with the modification of risk factors. Given the high risk of a bleed and the perceived low risk of additional embolus, in this rare instance no anticoagulation was given to a patient with documented pulmonary emboli.
The decision to anticoagulate requires a thorough analysis of risks and benefits, even when the indication is strong. In the face of a lifelong danger of significant bleeding, as in hereditary hemorrhagic telangiectasia, identifying and modifying prothrombotic risk factors may be a safer means of decreasing overall morbidity and mortality than anticoagulation.
J. Trambley, none.