A 58-year-old man with paroxysmal atrial fibrillation has a CHA₂DS₂-VASc score of 3 (hypertension, age 58–74, male sex). He has a HAS-BLED score of 2. Which statement regarding anticoagulation is CORRECT per current ACC/AHA guidelines?

• A Anticoagulation is optional; aspirin is an acceptable alternative
• B Anticoagulation should be withheld because HAS-BLED score indicates high bleeding risk
• C Warfarin is preferred over NOACs in non-valvular AF
• D Long-term anticoagulation with a NOAC is recommended (risk outweighs bleeding risk) ✓

Explanation

A CHA₂DS₂-VASc score ≥2 in males (≥3 in females) carries meaningful annual stroke risk; ACC/AHA 2023 AF guidelines recommend anticoagulation. A HAS-BLED score of 2 indicates intermediate bleeding risk — it identifies modifiable risk factors to correct, but a moderate HAS-BLED score is not a contraindication to anticoagulation (only scores ≥3 suggest high risk). NOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin in non-valvular AF due to superior efficacy and safety profiles. Aspirin is not an adequate substitute for anticoagulation in AF.

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

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Written and medically reviewed by the StethoPrep medical team.