A 62-year-old woman with persistent atrial fibrillation (AF) has a CHA₂DS₂-VASc score of 4 (hypertension, age 62, diabetes, female sex). She has no contraindications to anticoagulation. Per 2023 ESC/ACC guidelines, which anticoagulation strategy is preferred?
- A Aspirin 325 mg daily for thromboprophylaxis in non-valvular AF
- B Warfarin (target INR 2–3) as first-line in all patients with CHA₂DS₂-VASc ≥2
- C A non-vitamin K oral anticoagulant (NOAC: apixaban, rivaroxaban, or dabigatran) is preferred over warfarin ✓
- D Dual antiplatelet therapy (aspirin + clopidogrel) as an alternative to oral anticoagulation
Explanation
For non-valvular AF with CHA₂DS₂-VASc ≥2 in men (≥3 in women), oral anticoagulation is indicated. NOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin due to equivalent or superior stroke prevention, significantly lower rates of intracranial haemorrhage, and simpler dosing without routine INR monitoring — supported by RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE AF trials. Aspirin alone is not recommended for AF stroke prevention; it has similar bleeding risk to anticoagulation but substantially less stroke reduction. Warfarin remains appropriate in mechanical prosthetic valves or rheumatic mitral stenosis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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