A 66-year-old woman was admitted to the hospital because of lower gastrointestinal bleeding and heart failure. Ten years before this admission, the patient was diagnosed with rheumatic heart disease and mitral valve stenosis. Nine years before, she underwent mechanical mitral valve replacement. Since then, she had been taking furosemide 20 mg qd, spironolactone 25mg bid, digoxin 0.125 mg qd, and warfarin 1.875–3.125 mg to maintain international normalized ratio (INR) in target range. She also took metoprolol and perindopril inconsistently. The patient had been hospitalized several times due to gastrointestinal bleeding episodes within the last 2 years with two times unstable hemodynamics history and every time became stable attributed to suspending anticoagulant therapy, blood transfusion and other supportive treatments.
