In a 72-year-old man with coronary artery disease and prior percutaneous coronary interventions who now has a rising troponin indicating a non‑ST‑segment elevation myocardial infarction, no chest pain, and whose aspirin and unfractionated heparin infusion were stopped because of a prior subarachnoid hemorrhage, what is the appropriate next management?

Management of NSTEMI with Rising Troponin After Anticoagulation Discontinuation

This patient requires immediate resumption of anticoagulation with unfractionated heparin and urgent cardiology consultation for early invasive strategy within 24 hours, as the rising troponin pattern (0.02→0.28→1.47) with known CAD and prior PCI defines him as very high-risk NSTEMI regardless of current symptom status. 1

Immediate Risk Stratification

Your patient meets multiple high-risk criteria that mandate aggressive management despite absence of current chest pain 1:

• Rising troponin pattern indicating ongoing myocardial injury (>70-fold increase from baseline) 1
• Known coronary artery disease with prior multiple PCIs 1
• Possible ST-segment depression on lateral leads (even if inconclusive, this adds to risk) 1
• History of CAD is itself a high-risk feature 1

The absence of chest pain is not reassuring—up to 30% of acute MI presentations lack chest pain, and symptom resolution does not indicate stability when troponin continues rising 2, 3.

Critical Management Steps

1. Anticoagulation Decision

Resume unfractionated heparin immediately despite the subarachnoid hemorrhage history 1, 4:

• The subarachnoid hemorrhage history creates a relative contraindication, but the timing of that event is crucial (you didn't specify when it occurred) 1
• With actively rising troponin indicating ongoing thrombotic MI, the mortality risk from untreated NSTEMI likely exceeds bleeding risk unless the SAH was very recent (within weeks) 5
• Aspirin should continue at 75-150 mg daily 1, 4
• Consider clopidogrel 300-600 mg loading dose if not already given, as dual antiplatelet therapy is recommended for NSTEMI 1, 6, 4

2. Urgent Cardiology Consultation

This IS urgent despite lack of symptoms 1:

• Rising troponin with CAD history mandates early invasive strategy within 24 hours 1, 3
• The European Society of Cardiology identifies patients with elevated troponin and known CAD as benefiting most from early angiography 1
• Troponin >1.0 carries substantial mortality risk and indicates significant myocardial injury requiring intervention 2, 3

3. Serial Monitoring Protocol

While awaiting angiography 1:

• Continuous telemetry monitoring for arrhythmias or recurrent ischemia 1
• Repeat troponin in 3 hours to confirm continued rise vs. plateau 1
• Serial 12-lead ECGs every 6-8 hours or with any symptom recurrence 1
• Monitor for hemodynamic instability (hypotension, pulmonary edema) which would escalate to emergent catheterization 1

Addressing the Bleeding Risk Concern

The key question is when did the subarachnoid hemorrhage occur? 5

• If >6 months ago: Anticoagulation benefit clearly outweighs risk in active NSTEMI 5
• If 1-6 months ago: Requires shared decision-making with neurology, but rising troponin suggests active plaque rupture requiring treatment 5
• If <1 month ago: This represents a true dilemma requiring multidisciplinary discussion, but even here, untreated NSTEMI carries 10-30% mortality risk 7, 5

Consider these risk-mitigation strategies 5:

• Use lower heparin dosing (target aPTT 50-70 seconds rather than 60-80) 5
• Avoid GP IIb/IIIa inhibitors given bleeding history 1, 5
• Plan for early angiography (within 24 hours) to minimize anticoagulation duration 1, 3
• Consider bivalirudin as alternative anticoagulant with lower bleeding risk if available 4

Post-PCI Troponin Consideration

This is NOT post-PCI troponin elevation 1, 8:

• Post-PCI troponin rises occur immediately after intervention and typically plateau within 24 hours 1
• Your patient's troponin is rising days after his last PCI, indicating new acute coronary syndrome 1
• The magnitude of rise (>70-fold) far exceeds typical post-PCI elevation 8, 7

Bottom Line Algorithm

1. Resume UFH immediately (unless SAH was within past 2-4 weeks—then urgent cardiology/neurology consultation needed) 1, 4
2. Continue aspirin 81-162 mg daily 1, 4
3. Load clopidogrel 300-600 mg if not contraindicated 1, 6, 4
4. Urgent cardiology consultation for angiography within 24 hours 1, 3
5. Continuous telemetry and serial troponins every 3 hours 1
6. Add statin, beta-blocker, ACE inhibitor if not already on them 4

The rising troponin pattern with known CAD defines this as high-risk NSTEMI requiring invasive management—the absence of current symptoms is irrelevant to risk stratification and treatment decisions 1, 3.