A 58-year-old man with persistent atrial fibrillation has a CHA₂DS₂-VASc score of 3. He has no contraindications to anticoagulation. What is the recommended stroke prevention strategy per 2023 ACC/AHA/ACCP Atrial Fibrillation guidelines?

• A Aspirin 81 mg daily as stroke prophylaxis
• B Warfarin with INR 2–3 as preferred first-line anticoagulant
• C Left atrial appendage closure device instead of anticoagulation
• D Anticoagulation with a DOAC (preferred over warfarin) for CHA₂DS₂-VASc ≥2 in men ✓

Explanation

Per 2023 ACC/AHA/ACCP AF guidelines, oral anticoagulation is recommended for all non-valvular AF patients with CHA₂DS₂-VASc ≥2 in men (≥3 in women). DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) are preferred over warfarin due to superior net clinical benefit demonstrated in landmark trials (RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE-AF). Aspirin alone is not recommended for AF stroke prophylaxis (inferior efficacy with similar bleeding risk). LAA closure (WATCHMAN device) is reserved for patients with contraindications to long-term anticoagulation.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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