A 68-year-old man with persistent atrial fibrillation and CHA2DS2-VASc score of 4 (hypertension, age ≥65, diabetes, female sex absent). He has eGFR 52 mL/min. The PREFERRED anticoagulation is:
- A Direct oral anticoagulant (DOAC) — e.g., apixaban, rivaroxaban, or dabigatran — with dose adjustment for renal function ✓
- B Warfarin with target INR 2–3
- C Aspirin 300 mg daily as CHA2DS2-VASc is not high enough for anticoagulation
- D Heparin infusion indefinitely
Correct answer: A. Direct oral anticoagulant (DOAC) — e.g., apixaban, rivaroxaban, or dabigatran — with dose adjustment for renal function
Explanation
ESC 2020 AF guidelines recommend DOACs over VKAs (warfarin) for non-valvular AF in all patients with CHA2DS2-VASc ≥ 2 in men (≥ 3 in women) who are eligible for anticoagulation, as DOACs show comparable efficacy with superior safety (lower intracranial haemorrhage rates). With eGFR 52 mL/min, dose adjustment may be required (e.g., apixaban standard dose is suitable; dabigatran 110 mg twice daily if eGFR 30–50). Aspirin is NOT recommended as an alternative to anticoagulation for stroke prevention in AF.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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