A 55-year-old man with anterior STEMI treated with primary PCI 48 hours ago has an echocardiogram showing EF 35%, anterior wall akinesis, and an apical thrombus. He is in sinus rhythm. What is the recommended anticoagulation strategy?
- A Dual antiplatelet therapy alone is sufficient; anticoagulation is not indicated
- B Heparin infusion indefinitely for apical thrombus
- C Warfarin (INR 2–3) or a DOAC for 3–6 months alongside single antiplatelet therapy ✓
- D Rivaroxaban 20 mg daily added to dual antiplatelet (triple therapy) for 12 months
Correct answer: C. Warfarin (INR 2–3) or a DOAC for 3–6 months alongside single antiplatelet therapy
Explanation
LV thrombus post-anterior STEMI requires anticoagulation — warfarin targeting INR 2–3 for 3–6 months is guideline-recommended; DOACs (particularly rivaroxaban, apixaban) are increasingly used though evidence is less robust. Dual antiplatelet is typically reduced to single antiplatelet when anticoagulation is added to minimise bleeding. Triple therapy for 12 months carries excessive haemorrhagic risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.