What is the optimal management plan for a 72-year-old male with a recent history of cerebrovascular accident, atrial fibrillation, carotid artery stenosis, diabetes, coronary artery disease, and essential hypertension, presenting with impaired short-term memory, unsteady gait, and abnormal laboratory findings including elevated BUN, low vitamin D, and hyperlipidemia?

Optimal Management of Post-Stroke Patient with Multiple Cardiovascular Comorbidities

Continue rivaroxaban for atrial fibrillation-related stroke prevention and maintain aspirin for secondary stroke prevention, as dual therapy with rivaroxaban plus aspirin is specifically indicated for patients with coronary artery disease and provides superior cardiovascular protection compared to aspirin alone. 1, 2

Antithrombotic Strategy

Primary Anticoagulation:

• Continue rivaroxaban for atrial fibrillation given the embolic mechanism of the cerebellar stroke and CHADS2 score ≥2 (age >75, hypertension, recent stroke = 4 points, indicating 8.5% annual stroke risk without anticoagulation) 1
• Rivaroxaban is appropriate as the patient has established coronary artery disease (post-CABG), where the combination of rivaroxaban 2.5 mg twice daily plus aspirin 81-100 mg daily reduces major cardiovascular events (HR 0.76,95% CI: 0.66-0.86) compared to aspirin alone 2
• This dual therapy prevents 70 cardiovascular events per 10,000 patient-years while causing only 12 additional life-threatening bleeds, demonstrating favorable benefit-risk balance 2

Antiplatelet Therapy:

• Continue aspirin 81-325 mg daily for secondary stroke prevention following cerebral infarction, as antiplatelet agents are recommended over oral anticoagulants alone for noncardioembolic stroke prevention 1
• The combination of rivaroxaban plus aspirin is superior to aspirin monotherapy in patients with stable coronary artery disease and provides additional protection against recurrent vascular events 3, 4

Carotid Stenosis Management

>70% Left Internal Carotid Artery Stenosis:

• Urgent vascular surgery consultation is indicated for symptomatic carotid stenosis >70%, as revascularization should be performed within 14 days of symptom onset when feasible 1
• Carotid endarterectomy (CEA) is Class I recommendation for symptomatic patients with 70-99% stenosis, provided procedural death/stroke rate is <6% 1
• Continue dual antiplatelet therapy (aspirin plus clopidogrel) for minimum 30 days if carotid artery stenting (CAS) is performed instead of CEA 1
• Monitor with noninvasive imaging (duplex ultrasound, CTA, or MRA) at 1 month, 6 months, and annually after any revascularization procedure 1

Critical Pitfall: Do not delay revascularization evaluation—symptomatic carotid stenosis carries substantially higher stroke risk than asymptomatic disease, and early intervention (within 14 days) provides maximum benefit 1, 5

Lipid Management

Aggressive Statin Therapy:

• Initiate or uptitrate to high-intensity statin therapy (atorvastatin 80 mg daily or rosuvastatin 40 mg daily) to achieve LDL-C <70 mg/dL, as current LDL of 80 mg/dL remains above target 1, 6, 5
• Statins are Class I recommendation for all patients with extracranial carotid or vertebral atherosclerosis 6
• In diabetic patients with normal LDL levels, atorvastatin 10 mg daily reduces cardiovascular events by 37% and stroke by 48%, supporting statin use even when lipids appear controlled 1
• Recheck fasting lipid panel in 4-12 weeks after statin adjustment to confirm adequate LDL-C reduction 5
• Continue addressing low HDL (32 mg/dL) through lifestyle modifications including diet and exercise 1

Statin Pleiotropic Effects: Beyond cholesterol reduction, statins stabilize endothelial cells, increase nitric oxide bioavailability, reduce oxidative stress, and decrease vascular wall inflammation—mechanisms particularly beneficial in atherosclerotic disease 6

Blood Pressure Management

Hypertension Control:

• Continue current antihypertensive regimen (lisinopril, hydralazine, carvedilol) as blood pressures are stable (134/64,139/74 mmHg) and within target <140/90 mmHg 1
• Monitor closely for hypotension given recent medication adjustments, fall risk from ataxic gait, and elevated fall risk from cerebellar stroke 1
• Aggressive blood pressure control is more beneficial than glucose control alone in reducing recurrent stroke risk in diabetic patients 1

Critical Consideration: In patients with significant carotid stenosis and impaired cerebral perfusion, overly aggressive blood pressure reduction may compromise cerebral blood flow—maintain systolic BP 120-140 mmHg range 1

Diabetes Management

Glucose Control:

• Continue insulin glargine and sitagliptin with BID glucose monitoring given variability (BS 130 to 220 mg/dL) 1
• Strict glycemic control is Class I recommendation in diabetic patients with peripheral arterial diseases 1
• Aggressive control of cardiovascular risk factors is more important than glucose control alone for stroke prevention—prioritize blood pressure, lipids, and antiplatelet therapy 1

Realistic Expectation: The absolute stroke risk reduction from intensive glucose control is modest (number needed to treat = 626 per year), emphasizing the greater importance of managing other modifiable risk factors 1

Renal Function Monitoring

Elevated BUN Management:

• Monitor renal function with weekly CMP as ordered, given BUN 46 mg/dL with high BUN/Cr ratio (41), likely prerenal azotemia from volume depletion 2
• Encourage adequate oral fluid intake and reassess diuretic effect of chlorthalidone 1
• Current eGFR 69 mL/min is acceptable for rivaroxaban use (contraindicated only if eGFR <15 mL/min) 2

Vitamin D Supplementation

Vitamin D Deficiency (17.1 ng/mL):

• Initiate vitamin D replacement per facility protocol as vitamin D deficiency is associated with increased cardiovascular morbidity, mortality, and recurrent cardiovascular events 7
• Vitamin D deficiency occurs in 30-50% of the population and is emerging as a cardiovascular risk factor, particularly relevant in patients with established coronary artery disease, heart failure, and atrial fibrillation 7

Rehabilitation and Fall Prevention

Neurologic Recovery:

• Continue skilled physical therapy, occupational therapy, and speech therapy for ataxic gait, mobility deficits, and cognitive impairment (BIMS score 7) 1
• Maintain fall precautions given persistent unsteady gait with right-sided lean following cerebellar stroke 1
• Monitor for delirium or further cognitive decline, as cognitive deficits following cerebral infarction require ongoing assessment 1

Surveillance and Follow-Up

Structured Monitoring Plan:

• Weekly CMP for renal function and electrolyte monitoring
• Lipid panel in 4-12 weeks to assess statin efficacy
• Vascular surgery evaluation for carotid stenosis within 14 days
• Noninvasive carotid imaging at 1,6, and 12 months post-revascularization (if performed)
• Continue neurologic monitoring for new deficits or symptom progression

Critical Pitfall: Do not discontinue rivaroxaban and aspirin combination therapy—recent trial data (COMPASS) demonstrate this combination is terminated early only when harm exceeds benefit, which occurred with higher-dose rivaroxaban (not the 2.5 mg twice daily dose used here) 2, 4