Core points

• Confirm and classify the MI urgently: serial ECGs, troponins, echo if needed, hemodynamic assessment, and immediate cardiology input. Different management is needed for STEMI, NSTEMI, type-2 MI from anemia/hypoxia/hypotension, and postoperative myocardial injury.
• If STEMI or ongoing ischemia/shock: urgent primary PCI is generally the preferred reperfusion path. Fibrinolysis/thrombolysis is generally contraindicated or very hazardous after major surgery, because it can cause severe operative-site bleeding.
• DAPT:
  • Aspirin plus a P2Y12 inhibitor is standard ACS therapy, especially if PCI/stenting is performed. The 2025 ACC/AHA ACS guidance recommends DAPT as the default in ACS when bleeding risk is not high, but this patient is clearly high bleeding risk. See the AHA ACS guideline summary.
  • If a coronary stent is placed, stopping DAPT early can cause catastrophic stent thrombosis. The choice and timing of P2Y12 loading must therefore be decided with the interventional cardiologist and surgeon.
  • Before PCI or when diagnosis is uncertain, avoid reflexively giving a P2Y12 loading dose if it may preclude urgent re-operation or worsen active surgical bleeding.
• Clexane (enoxaparin):
  • Distinguish orthopedic VTE prophylaxis from full therapeutic anticoagulation for ACS. They are not interchangeable.
  • Therapeutic-dose enoxaparin only 12 hours after hip fracture fixation can substantially increase wound hematoma, ongoing bleeding, transfusion, and reoperation risk. LMWH also accumulates in significant renal impairment, increasing bleeding risk.
  • In an unstable postoperative ACS patient where anticoagulation is necessary and rapid reversibility is important, clinicians often consider an IV unfractionated heparin-based, PCI-directed strategy rather than committing to longer-acting therapeutic LMWH. This is a cardiology decision, not an automatic substitution.
  • If anticoagulation is temporarily unsafe because of active bleeding or insecure hemostasis, use mechanical VTE prevention while reassessing frequently. Hip-fracture patients normally need VTE prophylaxis, often combined with mechanical compression, but postoperative bleeding risk can override routine timing.

Immediate practical checklist

1. Activate cardiology/interventional cardiology now.
2. Inform operating orthopedic surgeon and anesthetist immediately.
3. Assess the wound and drains: expanding thigh/hip swelling, soakage, falling hemoglobin, hypotension, tachycardia.
4. Check CBC/platelets, PT/INR, aPTT, creatinine/eGFR, group and crossmatch.
5. Establish whether neuraxial anesthesia or an epidural catheter was used or remains in situ before escalating antithrombotics.
6. Clarify whether this is true plaque-rupture ACS or myocardial injury/type-2 MI from postoperative anemia, hypoxia, sepsis, PE, arrhythmia, or hypotension.
7. Document a single agreed plan for aspirin, P2Y12 agent, anticoagulant type, dose, timing, and bleeding-monitoring triggers.