A 62-year-old woman with persistent atrial fibrillation (AF) and CHA2DS2-VASc score of 4 has been on warfarin for 3 years. Her time in therapeutic range (TTR) is consistently 58%. She is keen to avoid INR monitoring. According to 2023 ESC AF guidelines, the preferred next step in anticoagulation management is:
- A Continue warfarin and optimize INR more frequently
- B Add antiplatelet agent (aspirin) to warfarin
- C Switch to a direct oral anticoagulant (DOAC, e.g., rivaroxaban or apixaban) ✓
- D Discontinue anticoagulation given low TTR
Explanation
A TTR <65–70% on warfarin is a strong indication to switch to a DOAC per ESC 2023 guidelines, as subtherapeutic anticoagulation exposes the patient to both stroke and bleeding risks without benefit. DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) have been shown non-inferior to warfarin in multiple landmark trials (ARISTOTLE, ROCKET-AF, ENGAGE-AF, RE-LY) with superior intracranial safety. In patients preferring to avoid INR monitoring or with poor TTR, DOAC is clearly preferred. Adding aspirin to subtherapeutic warfarin increases bleeding without stroke benefit. CHA2DS2-VASc ≥2 in women (≥3) mandates anticoagulation, not cessation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.