The question
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A 71-year-old man attends the cardiology clinic 4 weeks after a non-ST-elevation myocardial infarction treated by percutaneous coronary intervention with one drug-eluting stent to the left anterior descending artery. The procedure was uncomplicated, with no arrhythmia or hypotension afterwards, and he has had no further chest pain, no bruising and no bleeding.
PMH: Permanent atrial fibrillation for the past 3 years; hypertension; a Helicobacter pylori-associated duodenal ulcer 12 years ago, eradicated and healed, which never bled; no diabetes; no previous stroke or stent.
DH: apixaban 5 mg PO twice daily (12-hrly) (atrial fibrillation); aspirin 75 mg PO daily (after coronary stent); clopidogrel 75 mg PO daily (after coronary stent); lansoprazole 30 mg PO daily (gastroprotection during combined antithrombotic treatment); bisoprolol 5 mg PO daily; ramipril 5 mg PO daily; atorvastatin 80 mg PO nightly (all three after the infarction). No known drug allergies.
SH: Ex-smoker; drinks 6 units weekly; drives.
On examination: Temperature 36.6°C, HR 72/min and irregularly irregular, BP 128/76 mmHg, RR 14/min, O2 sat 97% breathing air. Weight 88 kg, body mass index 27.9 kg/m². Heart sounds normal, chest clear, no peripheral oedema and no raised jugular venous pressure. No bruising, no purpura and no melaena on rectal examination.
Investigations: Hb 143 g/L (130–175), WCC 6.8 ×10⁹/L (4.0–11.0), platelets 268 ×10⁹/L (150–400) Na⁺ 140 mmol/L (135–145), K⁺ 4.3 mmol/L (3.5–5.3), urea 5.8 mmol/L (2.5–7.0), creatinine 92 µmol/L (60–110), eGFR 77 mL/min/1.73 m² (>60) HbA1c 38 mmol/mol (<42) ALT 26 U/L (<41), bilirubin 11 µmol/L (<21) ECG: atrial fibrillation at 72/min, no ischaemic change
- continue apixaban 5 mg oral (PO) twice daily (12-hrly), aspirin 75 mg oral (PO) daily and clopidogrel 75 mg oral (PO) daily until 12 months after the stent
- stop the apixaban and continue aspirin 75 mg oral (PO) daily with clopidogrel 75 mg oral (PO) daily until 12 months after the stent
- stop the aspirin and continue apixaban 5 mg oral (PO) twice daily (12-hrly) with clopidogrel 75 mg oral (PO) daily until 12 months after the stent
- stop the aspirin and continue apixaban 5 mg oral (PO) twice daily (12-hrly) with ticagrelor 90 mg oral (PO) twice daily (12-hrly) until 12 months after the stent
- stop the aspirin and the clopidogrel and continue apixaban 5 mg oral (PO) twice daily (12-hrly) alone from today
Answer and marking
stop the aspirin and continue apixaban 5 mg oral (PO) twice daily (12-hrly) with clopidogrel 75 mg oral (PO) daily until 12 months after the stent
Marks2
ExplanationCorrect — stop the aspirin and continue apixaban 5 mg oral (PO) twice daily (12-hrly) with clopidogrel 75 mg oral (PO) daily until 12 months after the stent. NICE NG185 recommendation 1.4.22 gives the regimen in one sentence: 'For people already on anticoagulation who have had PCI, continue anticoagulation and clopidogrel for up to 12 months.' Aspirin is not in that sentence, and recommendation 1.4.21 explains why it is the one that goes: 'long-term continuation of aspirin, clopidogrel and oral anticoagulation (triple therapy) significantly increases bleeding risk.' The 2023 ESC acute coronary syndromes guideline puts a clock on it — anticoagulant plus a single antiplatelet, 'preferably clopidogrel', is 'the default strategy for up to 12 months after up to 1 week' of triple therapy — and he is 4 weeks out, so the aspirin is already overdue for withdrawal. The dose stays at apixaban 5 mg twice daily: he meets none of the three reduction criteria, being 71 rather than 80 or over, 88 kg rather than 60 kg or less, and having a creatinine of 92 rather than 133 micromol/L or more. The lansoprazole continues alongside, and at 12 months from the stent the clopidogrel stops and the apixaban carries on by itself.
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How to approach a planning management item
The repeatable method from the Planning Management section guide.
- Identify the problemDiagnosis or clinical state in one phrase: severe hypercalcaemia, new atrial fibrillation, stage 2 hypertension.
- Decide the urgencyIs the patient unstable? Stabilisation and reversal come before definitive treatment.
- Find the first-line pathwaySearch the condition. The treatment summary lists steps in order.
- Apply the modifiersAge under or over 55, family origin, eGFR, pregnancy, asthma: each moves the answer within the pathway.
- Check it is the next stepNot a later correct step. Not a second-line agent. The one thing that should happen now.
Before you submit
- Have I named the problem and its urgency?
- Is this the treatment summary's first-line step, not a later one?
- Have I applied every modifier the case gives me?
- Is anything needed before this step?
- Is the option contraindicated for this patient?
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