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Non-ST elevation acute coronary syndrome with atrial fibrillation — RACP Adult Medicine MCQ

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HardCardiologyNon-ST elevation acute coronary syndrome with atrial fibrillationRACP Adult Medicine

A 76-year-old man with atrial fibrillation taking apixaban presents with 2 hours of central chest pressure. ECG shows widespread ST depression and high-sensitivity troponin rises from 52 to 410 ng/L. Creatinine is 96 micromol/L and there is no active bleeding. Coronary angiography with PCI is planned. What is the most appropriate management?

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Correct answer: A — Use aspirin, clopidogrel and apixaban initially, then de-escalate antiplatelet therapy according to bleeding risk

This is high-risk NSTEACS requiring invasive management and antithrombotic therapy, while recognising that oral anticoagulation for atrial fibrillation increases bleeding risk. Contemporary Australian ACS guidance supports short-course combination therapy with later de-escalation; prolonged triple therapy is avoided. Aspirin alone undertreats a stented ACS patient, warfarin substitution is not routinely required, and thrombolysis is not used for NSTEACS.

Reference: National Heart Foundation of Australia/CSANZ Australian ACS Guideline 2025; AMH