Ongoing Chest Pain with Dynamic ECG Changes and Severe Renal Impairment

The combination of ongoing ischaemic chest pain, dynamic ST depression, and a rising high-sensitivity troponin indicates non-ST-elevation myocardial infarction, not stable angina. She is high risk because pain is ongoing, there are dynamic ECG changes, and troponin is rising. Renal impairment increases bleeding and contrast risk but does not justify avoiding angiography when the benefit is clear. Because she is not in cardiogenic shock and does not have refractory ischaemia, immediate angiography is not mandatory, but she should be treated as an urgent invasive case rather than a routine one. While awaiting the catheter laboratory, give anti-ischaemic therapy, monitor rhythm, and correct reversible factors such as hypertension and hypoxia. If she develops refractory pain, heart failure, arrhythmia, or haemodynamic instability, escalate to immediate angiography. The presence of a STEMI transfer should prompt a discussion about transfer to another centre rather than simply delaying her indefinitely.

She needs antiplatelet therapy for ACS but is already anticoagulated for atrial fibrillation, so the plan must balance ischaemic and bleeding risk. In the acute setting, give aspirin and a P2Y12 inhibitor, but avoid routine upstream glycoprotein IIb/IIIa inhibitors because of bleeding risk. For anticoagulation during angiography, use an intravenous agent that can be carefully dosed and monitored, and avoid adding full-dose parenteral anticoagulation on top of her recent apixaban without checking timing and coagulation status. After the procedure, she will usually need triple therapy for a limited period if a stent is placed, then dual therapy, then oral anticoagulation alone. The exact duration depends on bleeding risk, stent type, and whether she has another indication for antiplatelet therapy. Because eGFR is 32, avoid agents that accumulate in renal failure and review all doses. Do not stop apixaban abruptly without a plan, because stroke risk is substantial.

Monitor for contrast-associated AKI, bleeding, arrhythmia, heart failure, and recurrent ischaemia. Before contrast, ensure she is not hypovolaemic and use the lowest contrast volume consistent with diagnostic quality. After contrast, monitor urine output, creatinine at 48–72 hours, and potassium. Watch the access site and haemoglobin because she is anticoagulated and has received antiplatelet therapy. Telemetry is important because atrial fibrillation and ischaemia increase arrhythmia risk. If creatinine rises, review nephrotoxic drugs, maintain perfusion, and avoid further contrast unless essential. If she bleeds, stop antiplatelet or anticoagulant therapy according to severity and achieve local haemostasis. The main judgement is that renal impairment changes the choice and dose of drugs and contrast, but it should not become a reason to withhold reperfusion in a high-risk NSTEMI without a clear alternative plan.