A 55-year-old man with persistent atrial fibrillation (duration >12 months) and a CHA₂DS₂-VASc score of 4 has a HAS-BLED score of 2. Which anticoagulation strategy is appropriate?
- A Aspirin 100 mg alone is sufficient given HAS-BLED score of 2
- B Warfarin with INR 2–3 is preferred over DOACs in all AF patients
- C Direct oral anticoagulant (DOAC) — apixaban, rivaroxaban, or dabigatran — preferred over warfarin ✓
- D No anticoagulation needed until CHA₂DS₂-VASc reaches 5
Correct answer: C. Direct oral anticoagulant (DOAC) — apixaban, rivaroxaban, or dabigatran — preferred over warfarin
Explanation
With CHA₂DS₂-VASc ≥2 in males, anticoagulation is strongly recommended. DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over VKA (warfarin) for non-valvular AF in current ESC 2020 and AHA/ACC 2023 guidelines due to superior efficacy, safety, and convenience. HAS-BLED score of 2 is not high (threshold for concern is ≥3); even at ≥3, anticoagulation benefit outweighs bleeding risk. Aspirin does not adequately reduce cardioembolic stroke in AF. There is no threshold of CHA₂DS₂-VASc = 5 for starting anticoagulation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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