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:
- Paroxysmal atrial fibrillation (AF)
- Gastroesophageal reflux disease
- 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
- 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?