Should a 94-year-old male (94M) with sudden chest pain, on apixaban (apixaban), who improved with nitroglycerin (nitro), be given Aspirin (ASA) 321mg?

Management of Chest Pain in a 94-Year-Old Male on Apixaban with Response to Nitroglycerin

Aspirin 325mg should NOT be administered to this 94-year-old male patient on apixaban who experienced chest pain that improved with nitroglycerin, due to the significantly increased bleeding risk with dual antithrombotic therapy in this elderly patient. 1, 2

Initial Assessment and Risk Stratification

• This patient's presentation with chest pain that responds to nitroglycerin is concerning for possible acute coronary syndrome (ACS), but nitroglycerin response alone is not diagnostic of cardiac etiology 3, 4, 5
• Multiple studies have demonstrated that relief of chest pain with nitroglycerin does not reliably distinguish between cardiac and non-cardiac causes of chest pain 4, 5
• The patient's advanced age (94 years) and response to nitroglycerin warrant urgent evaluation for possible ACS despite the limitations of nitroglycerin response as a diagnostic tool 1

Antiplatelet Considerations in This Patient

• The patient is already on apixaban, which is an oral anticoagulant that significantly increases bleeding risk, especially in elderly patients 2
• Adding aspirin to existing anticoagulation therapy substantially increases the risk of bleeding complications, particularly in patients of advanced age (≥65 years) 1
• In patients ≥65 years who are already on anticoagulation (such as apixaban), the addition of aspirin is rated as "inappropriate" due to bleeding risk 1
• The risk of spontaneous hemorrhage, including intracranial bleeding, is significantly higher in elderly patients on apixaban, and this risk would be further elevated by adding aspirin 2

Management Algorithm

1. Do not administer aspirin 325mg due to the patient already being on apixaban and the high bleeding risk in this 94-year-old patient 1, 2

2. Activate emergency medical services immediately for this high-risk patient 6

   • Chest pain in a 94-year-old that responds to nitroglycerin requires urgent evaluation regardless of the diagnostic limitations of nitroglycerin response 1, 6

3. Continue appropriate use of nitroglycerin for symptom relief while awaiting emergency services 1

   • Nitroglycerin can be repeated every 5 minutes for a maximum of 3 doses if symptoms persist 1

4. Ensure rapid transport to an emergency department with cardiac capabilities 6

   • The patient should be placed on a cardiac monitor immediately upon arrival 1
   • An ECG should be performed and evaluated within 10 minutes of arrival 1

Important Considerations and Pitfalls

• Common pitfall: Assuming that response to nitroglycerin confirms cardiac etiology of chest pain. Multiple studies show this is not reliable 3, 4, 5

• Common pitfall: Automatically administering aspirin to all patients with suspected ACS without considering existing anticoagulation. In patients already on anticoagulants like apixaban, adding aspirin significantly increases bleeding risk, especially in the elderly 1

• Bleeding risk: The risk of serious bleeding complications, including intracranial hemorrhage, is substantially higher in elderly patients on apixaban, and this risk would be further increased by adding aspirin 2

• Age consideration: At 94 years old, this patient is at extremely high risk for bleeding complications from dual antithrombotic therapy 1, 2