What is the optimal management plan for a 74-year-old male patient with systemic hypertension, dyslipidemia, type 2 diabetes, diffuse atherosclerosis, cerebral vascular accidents (CVAs), peripheral arterial disease, atrial fibrillation, benign prostatic hyperplasia (BPH), chronic kidney disease stage IIIb, sacral decubitus ulcer, and recent upper gastrointestinal (GI) bleed, with coronary artery disease, acute coronary syndrome (ACS), and non-ST-elevation myocardial infarction (NSTEMI)?

Optimal Management Plan for a 74-Year-Old Male with Multiple Comorbidities, Recent GI Bleed, and NSTEMI

The optimal management plan for this patient should include discontinuing aspirin, continuing clopidogrel and rivaroxaban (Xarelto) 15 mg daily, along with medical management of his coronary artery disease until he can undergo elective revascularization. 1

Antithrombotic Management

Current Situation Assessment

• 74-year-old male with:
  • Recent upper GI bleed with duodenal ulcers requiring clip placement
  • NSTEMI with severe triple vessel disease
  • Atrial fibrillation requiring anticoagulation
  • CKD stage IIIb (affecting medication dosing)

Optimal Antithrombotic Regimen

1. Anticoagulation

   • Continue rivaroxaban (Xarelto) 15 mg daily as recommended by the cardiology team
   • Dose appropriately reduced from standard 20 mg due to CKD stage IIIb (CrCl ≤50 mL/min) 1

2. Antiplatelet Therapy

   • Continue clopidogrel 75 mg daily
   • Discontinue aspirin to reduce bleeding risk 1, 2

   This approach is supported by ESC guidelines which state: "For patients taking oral anticoagulation with an indication for DAPT (e.g., after STEMI), triple therapy should be carefully evaluated and continued only if compelling evidence exists" 1

Rationale for Single Antiplatelet + Anticoagulation

• The patient has a recent GI bleed, making triple therapy (aspirin + clopidogrel + anticoagulant) high risk
• The 2018 ESC guidelines support that "after discussion with cardiology and gastroenterology, transition to DOAC and Plavix and discontinue aspirin" is appropriate 1
• For patients with atrial fibrillation who undergo PCI or have ACS, dual therapy with a P2Y12 inhibitor (preferably clopidogrel) and an anticoagulant is recommended over triple therapy to reduce bleeding risk while maintaining antithrombotic efficacy 2

Coronary Artery Disease Management

Medical Management

• Continue beta-blocker (metoprolol succinate 50 mg twice daily)
• Continue statin therapy (high-intensity recommended)
• Continue Cardizem CD 180 mg daily for rate control of atrial fibrillation
• Continue pantoprazole 40 mg twice daily for GI protection

Revascularization Strategy

• Follow recommendation for outpatient elective PCI/CABG evaluation
• Schedule follow-up with cardiothoracic surgeon at Buffalo General Hospital within 1 week after discharge
• Medical management is appropriate initially given:
  • Recent GI bleed (increased procedural risk)
  • Significantly calcified vessels (technical complexity)
  • Stabilized condition with medical therapy

Additional Management Considerations

Atrial Fibrillation

• Continue rate control with current regimen
• Rivaroxaban 15 mg daily is appropriate for this patient with CKD stage IIIb and high stroke risk (CHA₂DS₂-VASc score likely >4 based on age, hypertension, diabetes, vascular disease, and prior stroke) 1

Decubitus Ulcer

• Continue frequent repositioning and wound care as recommended

Ischemic Colitis

• Monitor for resolution of mural thickening of cecum and ascending colon
• Completed antibiotics course as noted

Follow-up Plan

1. Cardiology Follow-up

   • Schedule appointment with cardiothoracic surgeon within 1 week
   • Arrange outpatient cardiology follow-up to reassess for elective revascularization

2. Medication Monitoring

   • Monitor for bleeding complications
   • Check renal function regularly (at least annually) to ensure appropriate dosing of rivaroxaban 1
   • Monitor INR if transitioning to warfarin in the future

3. Patient Education

   • Instruct patient on signs/symptoms of recurrent cardiac ischemia
   • Educate on bleeding precautions while on dual therapy
   • Provide clear instructions on medication purpose, dosing, and side effects 1

Important Considerations and Pitfalls

• Bleeding vs. Thrombotic Risk: This patient has both high bleeding risk (recent GI bleed, CKD, advanced age) and high thrombotic risk (NSTEMI, atrial fibrillation, prior strokes). The recommended approach balances these risks by using a single antiplatelet agent with anticoagulation.

• Anticoagulant Dosing: Rivaroxaban must be dose-adjusted for renal function. The 15 mg daily dose is appropriate for CrCl ≤50 mL/min 1.

• Duration of Therapy: Dual therapy with clopidogrel and anticoagulation should be continued for 12 months after ACS, after which anticoagulation alone may be sufficient 1, 2.

• Gastric Protection: Maintain PPI therapy (pantoprazole) to reduce GI bleeding risk while on antithrombotic therapy 1.

• Cardiac Rehabilitation: Enrollment in cardiac rehabilitation should be considered after discharge to enhance recovery and secondary prevention 1.