Warfarin, Aspirin, Both, or Neither: What Would You Prescribe?

A 67-year-old woman presents to you to establish medical care. She has no significant past medical history except hyperlipidemia. Specifically, she denies a previous history of hypertension, diabetes, stroke, or any cardiovascular problems. On examination, she is overweight (body mass index, 27) in no acute distress. Her heart rate is 98 beats/min irregularly irregular and her blood pressure is 108/62 mm Hg. ECG shows atrial fibrillation.

Based on the current ACC/AHA guidelines, which of the following would you recommend for this woman?

A. Both antithrombotic therapy and antiplatelet therapy are indicated.
B. Neither antithrombotic therapy nor antiplatelet therapy is indicated.
C. Either aspirin or warfarin therapy can be used.

Please make a selection, then click here for the answer and discussion.

Answer: C. Either aspirin or warfarin therapy can be used.

Anticoagulation should be initiated when the benefits of anticoagulation in preventing thromboembolism outweigh the risks. The main risk prediction score, the CHADS₂ [Congestive heart failure, HTN, Age>75 y, Diabetes, Stroke (2 points)] score can be used in most cases to determine the risk of thromboembolic complications, such as stroke. In patients with a CHADS2score of 0 or 1, the CHADS₂-VASC score (adds age > 65, peripheral vascular disease) provides higher sensitivity at lower ranges. In this woman, who is older than 65 years, either antithrombotic or antiplatelet therapy with aspirin is acceptable. There is controversy about which one is preferable in patients when CHADS₂ = 0 and CHADS2-VASC = 1 so at this time, either can be used. Since this woman also has multiple cardiac risk factors (hyperlipidemia, postmenopausal), a daily aspirin may be a good option.

Reference:
Kohli P. When the CHADS₂ score = 1, will aspirin do, or is warfarin indicated? Consultantlive.com. May 15, 2013.  http://www.consultantlive.com/atrial-fibrillation/content/article/10162/2142685.  Accessed October 18, 2013.