How should I evaluate and manage an 84‑year‑old man with atrial fibrillation on rivaroxaban, chronic chest pain, gastro‑esophageal reflux disease, well‑controlled type 2 diabetes mellitus, stable anemia who has not been taking pantoprazole and has had intermittent hemoptysis (coughing up blood clots) and occasional nasal bleeding for two weeks, with a mildly elevated troponin but a normal electrocardiogram?

Evaluation and Management of Hemoptysis in an Anticoagulated Patient

This patient requires urgent evaluation for the source of hemoptysis with chest imaging (CT chest with contrast) and direct laryngoscopy/bronchoscopy, while temporarily holding rivaroxaban until the bleeding source is identified and controlled. 1

Immediate Assessment and Bleeding Management

Assess hemodynamic stability and severity of bleeding:

• Check vital signs, oxygen saturation, and complete blood count to quantify anemia progression 1
• Determine if hemoptysis is minor (blood-streaked sputum), moderate (>20 mL/day), or severe (>100 mL/day or hemodynamically significant) 1
• Review recent hemoglobin/hematocrit trends—you note labs were stable 2 days ago, but repeat immediately given ongoing bleeding 1

For moderate bleeding on rivaroxaban, delay the next dose or discontinue treatment temporarily 1. Given this patient has intermittent hemoptysis for 2 weeks (not daily, 1-2 times on some days), this represents moderate bleeding requiring intervention.

Anticoagulation Management

Rivaroxaban should be held temporarily until the bleeding source is identified and controlled:

• Rivaroxaban has a half-life of 5-9 hours in elderly patients; anticoagulant effect diminishes within 24 hours of the last dose 1
• Do not restart anticoagulation until hemostasis is achieved and the bleeding source is addressed 1
• Check renal function (creatinine clearance) as this affects rivaroxaban clearance—particularly important in an 84-year-old 1, 2

The mildly elevated troponin (7.2) with normal EKG likely represents demand ischemia or chronic elevation, not acute coronary syndrome requiring dual antiplatelet therapy 1. This does not change anticoagulation management for atrial fibrillation.

Diagnostic Workup for Hemoptysis Source

Obtain chest CT with contrast to evaluate for:

• Pulmonary embolism (paradoxically can occur despite anticoagulation) 1
• Lung parenchymal disease (infection, malignancy, bronchiectasis) 1
• Pulmonary vasculature abnormalities 1

Arrange direct visualization:

• ENT evaluation for nasopharyngeal source given history of nasal bleeding 1
• Pulmonology consultation for bronchoscopy if chest imaging suggests lower respiratory source 1

Consider additional testing:

• Coagulation studies: PT/INR and anti-Xa activity to assess residual rivaroxaban effect 1, 3
• Complete metabolic panel to assess renal function (rivaroxaban is renally cleared) 1, 2

Address GERD and PPI Non-Adherence

Restart pantoprazole immediately:

• Non-adherence to PPI in a patient with GERD on anticoagulation significantly increases gastrointestinal bleeding risk 1
• While hemoptysis is the presenting complaint, ensure no concurrent upper GI bleeding (hematemesis vs. hemoptysis differentiation) 1
• PPI should be continued long-term when anticoagulation is resumed 1

Common Pitfall: The Elevated Troponin

Do not add antiplatelet therapy based on the troponin elevation alone:

• The troponin of 7.2 with normal EKG and chronic chest pain suggests chronic elevation or demand ischemia, not acute MI requiring dual antiplatelet therapy 1
• Adding aspirin or clopidogrel to rivaroxaban dramatically increases bleeding risk (15% overall bleeding rate becomes much higher with combination therapy) 1, 4
• The patient's chronic chest pain is likely related to GERD (given the diagnosis and PPI non-adherence) rather than acute coronary syndrome 1

Restarting Anticoagulation

Once hemostasis is achieved and the source is controlled:

• Resume rivaroxaban at appropriate dose based on renal function: 20 mg daily if CrCl >50 mL/min, 15 mg daily if CrCl 30-50 mL/min 1, 5
• Rivaroxaban anticoagulant effect returns within 2-4 hours of the first dose 1
• No bridging with low molecular weight heparin is required given rivaroxaban's rapid onset 1

The patient's CHA₂DS₂-VASc score is ≥4 (age ≥75 [2 points], diabetes [1 point], male sex [0 points], likely hypertension given age)—oral anticoagulation is mandatory for stroke prevention 6. The bleeding risk must be balanced against very high stroke risk (>4% annually without anticoagulation).

Critical Monitoring After Resumption

Assess bleeding risk using HAS-BLED score:

• This patient likely has HAS-BLED ≥3 (age >65, renal dysfunction possible, labile INRs not applicable, drugs/alcohol unknown, prior bleeding) indicating high bleeding risk 1
• High HAS-BLED does not contraindicate anticoagulation but mandates closer monitoring and addressing modifiable risk factors 1

Ensure PPI adherence and address all modifiable bleeding risk factors before restarting anticoagulation 1.