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NSTEMI in a patient taking a direct oral anticoagulant — SCE Acute Medicine MCQ

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ModerateCardiovascular medicineNSTEMI in a patient taking a direct oral anticoagulantSCE Acute Medicine

A 79-year-old woman on apixaban for atrial fibrillation presents with chest pain and dynamic ST depression. Troponin is elevated, haemoglobin is 112 g/L and eGFR is 42 mL/min/1.73 m2. She is pain-free after nitrates and is planned for early invasive angiography. What is the most appropriate next antithrombotic strategy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Discuss with cardiology and avoid routine upstream dual antiplatelet loading before coronary anatomy is known

In NSTEMI already anticoagulated with a DOAC, antithrombotic treatment should be individualised with cardiology because bleeding risk is substantial and routine upstream P2Y12 loading before angiography may be inappropriate. Thrombolysis has no role in NSTEMI. The pearl is that ACS pathways need modification when long-term anticoagulation is already present.

Reference: NICE NG185 acute coronary syndromes; ESC NSTE-ACS guidance