Antithrombotic Therapy for SIHD and AF

A 55-year-old Caucasian male patient presented to the office for a follow-up visit. He was a former smoker with type 2 diabetes mellitus, hypertension, and hyperlipidemia who had an anterior wall myocardial infarction (MI) 15 months ago that was treated with percutaneous coronary intervention (PCI) with a drug-eluting stent to the left anterior descending artery. Non-obstructive coronary artery disease of the right coronary and left circumflex arteries was noted on the angiogram. He was also noted to have paroxysmal episodes of atrial fibrillation (AF) during the MI hospitalization. Echocardiography showed normal left ventricular systolic function. He was treated with aspirin 81 mg daily, ticagrelor 90 mg twice daily, and rivaroxaban 20 mg daily for the first month following the PCI, after which aspirin was discontinued. He did not have any hospitalizations since his initial presentation, and he has been compliant with his medical therapy. He does aerobic exercises for 1 hour 4 times a week without any limiting angina or dyspnea.

On exam, his BMI was 28, temperature was 98.6 °F, heart rate was 86 bpm, and blood pressure was 124/76 mmHg. The cardiovascular exam was otherwise unremarkable. His electrocardiogram (ECG) demonstrated normal sinus rhythm. Ambulatory ECG monitoring after the MI confirmed the presence of episodes of paroxysmal AF. His lipid panel showed a total cholesterol of 130 mg/dL: high-density lipoprotein of 42 mg/dL and low-density lipoprotein of 68 mg/dL. Hemoglobin A1c was 7.3%. His current medications were ticagrelor 90 mg twice daily, rivaroxaban 20 mg daily, metoprolol succinate 100 mg daily, atorvastatin 80 mg daily, metformin 1gm twice daily, and liraglutide.

Which of the following options would be the most appropriate choice of antithrombotic regimen for this patient in light of latest evidence?

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