Does a male patient with a CHADS2 (Congestive heart failure, Hypertension, Age ≥ 75, Diabetes, Stroke or transient ischemic attack) VASc (Vascular disease, Age 65-74, Sex category) score of 1 require Eliquis (apixaban)?

Anticoagulation for Male Patient with CHA₂DS₂-VASc Score of 1

For a male patient with a CHA₂DS₂-VASc score of 1, oral anticoagulation therapy should be considered based on individual risk assessment, but is not mandatory. 1

Risk Assessment and Recommendations

The CHA₂DS₂-VASc score is the recommended tool for stroke risk stratification in patients with atrial fibrillation. For male patients with a score of 1 (representing one risk factor beyond sex), the guidelines provide the following recommendations:

• European Society of Cardiology (ESC) Guidelines: Oral anticoagulation therapy should be considered (Class IIa recommendation) 1
• American College of Cardiology/American Heart Association (ACC/AHA) Guidelines: Oral anticoagulation may be considered, but is not mandatory 1

Risk Stratification by Specific Risk Factor

Not all risk factors in the CHA₂DS₂-VASc score carry equal weight for a male patient with a score of 1:

• Age 65-74 years: Highest risk factor (annual stroke rate ~3.50%) 2
• Diabetes mellitus: Moderate risk (annual stroke rate ~2.73%) 2
• Heart failure: Moderate risk (annual stroke rate ~2.35%) 2
• Hypertension: Moderate risk (annual stroke rate ~2.27%) 2
• Vascular disease: Lowest risk (annual stroke rate ~1.96%) 2

Decision Algorithm

1. Identify which specific risk factor contributes to the score of 1:

   • If age 65-74: Higher consideration for anticoagulation
   • If vascular disease alone: Lower priority for anticoagulation

2. Assess bleeding risk:

   • Calculate HAS-BLED score
   • Identify and address modifiable bleeding risk factors

3. Consider patient preferences:

   • Discuss the annual stroke risk (1.96-3.50% depending on risk factor)
   • Discuss bleeding risks with anticoagulation

4. If anticoagulation is chosen:

   • Direct oral anticoagulants (DOACs) like apixaban (Eliquis) are preferred over warfarin 1
   • Apixaban has demonstrated superior efficacy to warfarin with fewer major bleeds 3

Important Considerations

• The annual stroke risk for male patients with a CHA₂DS₂-VASc score of 1 ranges from 1.96% to 3.50% per year depending on the specific risk factor 2
• This risk is significantly higher than for patients with a score of 0 (truly low risk), who have an annual stroke risk <1% 4, 5
• Antiplatelet therapy alone is not recommended for stroke prevention in AF patients regardless of stroke risk 1

Pitfalls to Avoid

• Don't automatically prescribe anticoagulation for all CHA₂DS₂-VASc scores of 1 without considering the specific risk factor
• Don't substitute aspirin for oral anticoagulation, as it is ineffective for stroke prevention in AF and still carries bleeding risk 1
• Don't ignore patient preferences in the decision-making process, as this is a preference-sensitive decision
• Don't forget to reassess stroke and bleeding risk periodically, as risk factors may change over time

Remember that stroke prevention decisions should be made after discussing risks and benefits with the patient, particularly since a score of 1 represents a borderline indication for anticoagulation.