Management of Bleeding Complications in Patients With Chronic Lymphocytic Leukemia

A 68-year-old man with chronic lymphocytic leukemia (CLL) presents to the emergency department with a 1-day history of melena, chest discomfort and lightheadedness.

Background history includes:

  • Hypertension
  • Paroxysmal atrial fibrillation (AF)
  • Gastroesophageal reflux disease
  • Hyperlipidemia
  • Prior 20 pack-year tobacco use

Current medications include:

  • Metoprolol tartrate 25 mg twice daily
  • Losartan 50 mg once daily
  • Atorvastatin 40 mg once daily
  • Famotidine 20 mg once daily as needed
  • Ibrutinib 480 mg once daily
  • Apixaban 5 mg twice daily

Physical examination is notable for:

  • Vital signs blood pressure 85/60 mm Hg, hear rate 100 bpm, oxygen saturation 99%
  • Irregularly irregular rhythm, no murmurs

Electrocardiography: AF with HR 100 bpm, new T-wave inversions in inferolateral leads

Laboratories reveal:  

  • White  blood cell count 13,000/mL, hemoglobin 6 mg/dL, hematocrit 19%, platelets 200,000/mcL
  • High-sensitivity troponin 300 ng/L

After supportive measures (including transfusion), esophagogastroduodenoscopy reveals multiple bleeding ulcers, which are cauterized.

How would you manage the risk of stroke given the history of gastrointestinal (GI) bleeding?

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