A 74-year-old male with persistent atrial fibrillation has a CHA2DS2-VASc score of 4. Which anticoagulant therapy is recommended for long-term stroke prevention in the absence of mechanical prosthetic valves or mitral stenosis?

Answer and explanation

Correct answer: D. Direct oral anticoagulant (DOAC, e.g., apixaban or rivaroxaban)

  1. Step 1: In non-valvular atrial fibrillation with a CHA2DS2-VASc score >= 2 in men or >= 3 in women, oral anticoagulation is strongly recommended to reduce thromboembolic stroke risk.
  2. Step 2: Direct oral anticoagulants (DOACs: apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over vitamin K antagonists (warfarin) due to lower risks of intracranial hemorrhage and no requirement for routine INR monitoring.
Answer
Direct oral anticoagulant (DOAC, e.g., apixaban or rivaroxaban).
Why not the others: 'Aspirin 81 mg daily' and 'Clopidogrel 75 mg daily' provide minimal protection against cardioembolic stroke and are not recommended as monotherapy; 'Subcutaneous unfractionated heparin' is used in acute inpatient settings, not for outpatient maintenance.

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