Scenario

A normally well 76-year-old lady had an NSTEMI 2 years ago and had successful stenting with a drug eluting stent (DES) for a severe left anterior descending artery narrowing. She had residual mild diffuse disease elsewhere.

After 12 months of dual antiplatelet therapy with Aspirin and Ticagrelor, she is now on Aspirin, in addition to Atorvastatin 40mg and Cilazapril 2.5mg for hypertension.

When seen in clinic, she reported no angina but was found to have new incidental asymptomatic atrial fibrillation. She had no history of stroke or TIA.

The best strategy for managing her stroke risk is

1) Aspirin alone

2) Aspirin plus Warfarin

3) Aspirin plus Dabigatran

4) Warfarin alone

5) Dabigatran alone

Discussion

Her CHA2DS2VASC score is high at 5 indicating an annual stroke risk of 6.7%. She will require anticoagulation.

The more conclusive evidence of Aspirin is after an ACS and certainly in the first 6-12 months after a DES.

The combination of Aspirin and oral anticoagulation (Warfarin or newer novel oral anticoagulant) increases the risk of bleeding (especially gastrointestinal) without additional vascular benefit.

The aspirin could be stopped and oral anticoagulation started. If a novel oral anticoagulant is chosen, one needs to be cautious with the usual contraindications, including advanced age and renal function.

Author

Dr Seif El-Jack