An 85-year-old woman is referred to your cardiology clinic because of an incidental finding of atrial fibrillation at a routine check-up. The patient is asymptomatic from a cardiovascular perspective, but a 24-hour tape organized by the GP shows atrial fibrillation throughout with rates varying between 60 and 110 bpm. The patient has a history of hypertension and stable angina. Coronary angiography performed several years ago showed minor atheroma in the LAD, circumflex, and RCA. Echocardiography shows good biventricular systolic function with a left atrial diameter of 5.2 cm. The patient is on aspirin 75 mg od, ramipril 10 mg od, simvastatin 20 mg od, and atenolol 50 mg od.
What thromboprophylactic treatment do you recommend?
This patient has a CHADS2 score of 2 and a CHA2DS2VASc score of 3. Therefore she should be warfarinized. There is no evidence for a lower INR target range for elderly patients, but studies do suggest a twofold increase in the risk of stroke if the INR range is 1.5–2.0. This woman appears to have stable coronary artery disease, and there is no evidence to suggest that adding aspirin to warfarin reduces the risk of stroke or vascular events in this population (although it does increase the bleeding risk). In elderly patients with minimal symptoms it is reasonable not to pursue a rhythm control strategy.