A 78-year-old man comes to the office for routine follow-up. He had an ischemic stroke 8 months ago and has some residual weakness in his left leg. The patient had a fall 4 months ago without significant injuries, but his gait is somewhat unsteady. Medical history is significant for diet-controlled type 2 diabetes mellitus, hypertension, chronic kidney disease, and persistent atrial fibrillation. Current medications are lisinopril, metoprolol, atorvastatin, and low-dose aspirin. The patient has been treated with warfarin due to atrial fibrillation, but he found it difficult to follow frequent blood checks and stopped the therapy. He is a lifelong nonsmoker and does not drink alcohol. Despite leg weakness, he enjoys short walks in his yard every morning.
Blood pressure is 133/76 mm Hg, and pulse is 88/min and irregular. No murmurs are heard on cardiac auscultation, and there is no peripheral edema.
Laboratory results are as follows:
Estimated glomerular filtration rate (eGFR) is 39 mL/min. ECG shows atrial fibrillation and voltage criteria for left ventricular hypertrophy.
Which of the following is the best therapy to offer this patient?

Question

A 78-year-old man comes to the office for routine follow-up.  He had an ischemic stroke 8 months ago and has some residual weakness in his left leg.  The patient had a fall 4 months ago without significant injuries, but his gait is somewhat unsteady.  Medical history is significant for diet-controlled type 2 diabetes mellitus, hypertension, chronic kidney disease, and persistent atrial fibrillation.  Current medications are lisinopril, metoprolol, atorvastatin, and low-dose aspirin.  The patient has been treated with warfarin due to atrial fibrillation, but he found it difficult to follow frequent blood checks and stopped the therapy.  He is a lifelong nonsmoker and does not drink alcohol.  Despite leg weakness, he enjoys short walks in his yard every morning.
Blood pressure is 133/76 mm Hg, and pulse is 88/min and irregular.  No murmurs are heard on cardiac auscultation, and there is no peripheral edema.
Laboratory results are as follows:
 Estimated glomerular filtration rate (eGFR) is 39 mL/min.  ECG shows atrial fibrillation and voltage criteria for left ventricular hypertrophy.
Which of the following is the best therapy to offer this patient?

Quizplus · Accepted Answer

This patient with atrial fibrillation is at high risk of systemic thromboembolism based on a CHA₂DS₂-VASc score of 6, corresponding to an estimated annual risk of ischemic stroke of 9.7%; chronic kidney disease (CKD) may increase this risk even further. Chronic anticoagulation can greatly reduce the risk of a recurrent, potentially devastating stroke in this patient; however, careful consideration is required as he has risk factors for bleeding and hemorrhagic stroke (eg, advanced age, falls), and CKD also increases his bleeding risk. The HAS-BLED scoring system, which is derived from a cohort of patients taking warfarin, estimates this patient's risk of bleed at 1 year at 5.8% (total score = 3). annual risk of ischemic stroke risk of bleed at 1 year Large cohort studies support that there is typically a positive net clinical benefit of chronic anticoagulation in patients with atrial fibrillation and high thromboembolic risk. In this patient, the use of a direct oral anticoagulant (DOAC), including a direct thrombin inhibitor (eg, dabigatran) or a factor Xa inhibitor (eg, apixaban, rivaroxaban), is most appropriate. Compared to warfarin, these drugs have demonstrated similar or reduced rates of ischemic stroke and a reduced risk of major bleeding and hemorrhagic stroke in patients with CKD and estimated glomerular filtration rate (eGFR) >30 mL/min. (Choice A) Aspirin monotherapy is significantly less effective at reducing the thromboembolic risk compared to antithrombotic therapy with warfarin or a DOAC, and is not recommended. (Choice B) Although this patient's risk of major bleeding is elevated, his risk of thromboembolic stroke is significantly higher, and the benefits of anticoagulation likely outweigh the risks. (Choice D) There is insufficient data on the safety and efficacy of DOAC use in patients with severe kidney disease (eGFR <30 mL/min); therefore, warfarin is preferred in these patients. However, DOAC use is preferred in patients with estimated eGFR >30 mL/min. (Choice E) Fall risk increases the chances of head injury and resulting intracranial hemorrhage; however, this is outweighed by the risk of thromboembolic stroke in this patient. DOAC use is preferred over warfarin use. Educational objective: There is typically a positive net clinical benefit of chronic anticoagulation in patients with atrial fibrillation and high thromboembolic risk. Compared to warfarin, direct oral anticoagulants (eg, dabigatran, apixaban, rivaroxaban) are associated with similar or reduced rates of ischemic stroke and a reduced risk of major bleeding in patients with atrial fibrillation and chronic kidney disease with estimated glomerular filtration rate >30 mL/min. __________ References: Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: a net clinical benefit analysis using a 'real world' nationwide cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/21789337) 2014 AHA/ACC/HRS guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. (http://www.ncbi.nlm.nih.gov/pubmed/24682347) Major bleeding and hemorrhagic stroke with direct oral anticoagulants in patients with renal failure: systemic review and meta-analysis of randomized trials. (http://www.ncbi.nlm.nih.gov/pubmed/26836922) Stroke and bleeding in atrial fibrillation with chronic kidney disease. (http://www.ncbi.nlm.nih.gov/pubmed/22894575)

A 78-Year-Old Man Comes to the Office for Routine Follow-Up