What is the recommended management for a 75-year-old patient with paroxysmal atrial fibrillation (AFib) and a CHA2DS2-VASc score of 2?

Management of Paroxysmal Atrial Fibrillation in a 75-Year-Old with CHA₂DS₂-VASc Score of 2

Oral anticoagulation therapy is strongly recommended for this 75-year-old patient with paroxysmal atrial fibrillation and a CHA₂DS₂-VASc score of 2, with direct oral anticoagulants (DOACs) preferred over warfarin to prevent stroke and thromboembolism. 1

Risk Assessment and Indication for Anticoagulation

The patient has a CHA₂DS₂-VASc score of 2 based on age alone (75 years = 2 points). According to current guidelines:

• The 2018 CHEST guidelines strongly recommend stroke prevention for patients with AF, including paroxysmal AF, who have 1 or more non-sex CHA₂DS₂-VASc stroke risk factors 1
• The 2014 AHA/ACC/HRS guidelines specifically recommend oral anticoagulants for patients with nonvalvular AF with a CHA₂DS₂-VASc score of 2 or greater 1
• The 2024 ESC guidelines reinforce that oral anticoagulation is indicated for patients with AF and a CHA₂DS₂-VASc score ≥1 in men or ≥2 in women 1

Anticoagulation Options

Preferred First-Line Therapy: Direct Oral Anticoagulants (DOACs)

DOACs are recommended over warfarin for this patient unless they have contraindications such as mechanical heart valves or moderate-to-severe mitral stenosis 1. Options include:

1. Apixaban: 5 mg twice daily (reduce to 2.5 mg twice daily if patient meets dose reduction criteria)
2. Dabigatran: 150 mg twice daily (consider 110 mg twice daily if high bleeding risk)
3. Rivaroxaban: 20 mg once daily with evening meal (reduce to 15 mg daily if CrCl 30-50 mL/min) 2
4. Edoxaban: 60 mg once daily (reduce to 30 mg daily if CrCl 30-50 mL/min or weight ≤60 kg)

Benefits of DOACs over warfarin:

• No need for regular INR monitoring
• Fewer food and drug interactions
• Lower risk of intracranial hemorrhage
• At least equivalent efficacy for stroke prevention 3

Alternative Option: Warfarin

If DOACs are contraindicated or unavailable, warfarin with a target INR of 2.0-3.0 is recommended 4:

• INR should be monitored at least weekly during initiation
• Monthly monitoring when stable
• Target time in therapeutic range >70% 1, 3

Bleeding Risk Assessment

A bleeding risk assessment should be performed at every patient contact 1:

1. Use the HAS-BLED score to identify modifiable bleeding risk factors
2. Address modifiable risk factors:
   • Control blood pressure
   • Minimize alcohol consumption
   • Avoid concomitant NSAIDs or unnecessary antiplatelet therapy
   • Optimize renal and liver function

Important: A high bleeding risk score (HAS-BLED ≥3) should not lead to withholding anticoagulation but rather to closer monitoring and correction of modifiable risk factors 3.

Important Considerations and Pitfalls

1. Do not use antiplatelet therapy alone: Aspirin monotherapy or dual antiplatelet therapy is not recommended for stroke prevention in AF regardless of stroke risk 1, 3

2. Regular reassessment: Periodically reevaluate the need for and choice of anticoagulation therapy to reassess stroke and bleeding risks 1

3. Renal function: Evaluate renal function before initiating DOACs and reassess at least annually, as dose adjustments may be needed with declining renal function 3

4. Medication adherence: Ensure patient understands the importance of strict adherence to the prescribed anticoagulation regimen

5. Drug interactions: Consider potential interactions with other medications when selecting an anticoagulant

The evidence strongly supports that this 75-year-old patient with paroxysmal AF and a CHA₂DS₂-VASc score of 2 will benefit from oral anticoagulation therapy, with DOACs being the preferred option to reduce the risk of stroke while minimizing bleeding complications.