A 65-year-old diabetic man with a previous history of myocardial infarction 3 years ago (no intervention required) is found to have atrial fibrillation. His LVEF is 55% and he has no cardiovascular symptoms.
What would you advise him with regard to the best thromboprophylaxis?
This man has a CHADS2 score of 1 (one point for diabetes) and therefore could be offered warfarin or aspirin thromboprophylaxis according to this risk stratification system. However, if the newer CHA2DS2-VASc system is used, he has a score of 3 ( one point for each of DM, age 65–74, and previous MI) and should be offered oral anticoagulation (warfarin or newer agents). A CHA2DS2-VASc score of zero is truly low risk and could be managed with no thromboprophylaxis at all or aspirin (no thromboprophylaxis preferable). A CHA2DS2-VASc score of 1 could be managed with aspirin or oral anticoagulation (the latter is preferable). A score ≥2 should be managed with oral anticoagulation. In summary oral anticoagulation is preferred to aspirin in AF patients with one or more stroke risk factors based on the CHA2DS2-VASc score. In the absence of recent ACS or coronary artery stenting, there is no good evidence for either warfarin or antiplatelet drugs.