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Anticoagulation in Thrombocytopenia — EECC MCQ

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HardArrhythmia & ElectrophysiologyAnticoagulation in ThrombocytopeniaEECC

A 58-year-old man with stable AF on apixaban is diagnosed with cancer and requires chemotherapy that may cause severe thrombocytopenia (platelets <50 × 10⁹/L). At what platelet count should anticoagulation be modified?

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Correct answer: D — Dose reduction or temporary cessation of anticoagulation should be considered when platelets fall below 50 × 10⁹/L; anticoagulation is generally contraindicated below 25 × 10⁹/L

Thrombocytopenia introduces a significant bleeding risk that must be balanced against stroke risk in AF. General guidance (from ESC AF Guidelines and cardio-oncology consensus): platelets >50 × 10⁹/L — full-dose anticoagulation generally safe; platelets 25-50 × 10⁹/L — consider dose reduction or temporary interruption, individualised risk-benefit assessment; platelets <25 × 10⁹/L — anticoagulation generally held due to high bleeding risk. DOACs were not studied in severely thrombocytopenic patients (excluded from pivotal trials). Cancer-associated thrombocytopenia requires multidisciplinary discussion (cardiology, oncology, haematology). Alternative stroke prevention (LAAO) may be considered for patients requiring long-term anticoagulation interruption.

Reference: ESC (2024): AF Guidelines; ESC (2022): Cardio-Oncology Guidelines