Atrial Fibrillation: The Daily PANCE Blueprint

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Atrial Fibrillation: The Daily PANCE Blueprint

A 74-year-old woman with hypertension and type 2 diabetes mellitus presents for follow-up after an episode of palpitations. She has no chest pain or dyspnea and is hemodynamically stable. An ECG shows atrial fibrillation with an irregularly irregular rhythm and no discrete P waves. She has a remote history of a transient ischemic attack. Echocardiography shows normal valves with no mitral stenosis. Which of the following is the most appropriate therapy to reduce her risk of stroke?

A. Apixaban
B. Aspirin
C. Clopidogrel
D. Warfarin with a target INR of 2.0–3.0
E. No antithrombotic therapy

Answer and topic summary

The answer is A. Apixaban.

Her CHA2DS2-VASc score is high (age ≥65, female sex, hypertension, diabetes, and a prior TIA), so oral anticoagulation is indicated for stroke prevention. Per the 2023 ACC/AHA/ACCP/HRS atrial fibrillation guideline, a direct oral anticoagulant (DOAC) such as apixaban is preferred over warfarin for most patients with nonvalvular atrial fibrillation — comparable or better efficacy with lower bleeding risk and no INR monitoring. Warfarin is reserved for a mechanical heart valve or moderate-to-severe mitral stenosis (neither present here). Antiplatelet therapy (aspirin, clopidogrel) is inadequate for stroke prevention in atrial fibrillation, and withholding therapy leaves a high-risk patient unprotected.

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Covered under ⇒ PANCE Blueprint Cardiology ⇒ Conduction Disorders ⇒ Atrial Fibrillation/Flutter

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