Elevated Troponin in a 77-Year-Old Man Presenting to the Emergency Department

A 77-year-old man presents to the emergency department with chest pain. He reports a progressive decline in his exercise capacity over the past 6 months due to worsening chest pain with activity. Today, he was playing with his grandchildren when he developed sudden onset of severe, sub-sternal chest pain. After 30 minutes of rest, his pain persisted and he was still unable to catch his breath, prompting him to seek medical care.

His past medical history is notable for atrial fibrillation, hypertension, hyperlipidemia, and type 2 diabetes mellitus. There is no history of heart failure, stroke or TIA. The outpatient medications include lisinopril, metoprolol, atorvastatin, and warfarin, titrated to an INR goal of 2.0-3.0 (for atrial fibrillation with CHADS2 = 3).

Laboratory values are notable for an elevated troponin and CK-MB. Electrocardiogram shows 3-4 mm ST depressions in leads V2-V5. Coronary angiography reveals a 95% stenosis of the proximal left anterior descending artery, for which a bare metal stent is placed.

He spends two days in the hospital without complications.

At the time of discharge, what is the most appropriate antithrombotic strategy for this patient?

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