A 67-year-old woman presents with left calf pain occurring with ambulation that resolves with rest. Her symptoms occur at approximately one half mile of brisk walking and resolve quickly. She has a history of smoking but is otherwise healthy. She is taking no medications. On exam she is well-appearing. Her limbs show palpable dorsalis pedis pulses bilaterally but the left appears slightly diminished relative to the right. You perform an ankle brachial index which is 0.80 on the left and 0.90 on the right and decide to start aspirin 81 mg.
The patient returns for a routine follow-up visit six months later. Her leg symptoms are still present but are improved with exercise. She mentions that she has occasional palpitations but otherwise feels well. You perform an EKG which shows atrial fibrillation.
Based on this patient's history and risk for stroke, what is the most appropriate antithrombotic strategy for this patient?
Show Answer
The correct answer is: C. Aspirin (or clopidogrel) in addition to an oral anticoagulant
Like the CHADS2 score, the CHA2DS2-VASc score estimates the risk of stroke or systemic embolism. It expands risk factors beyond the CHADS2 score components by including three age ranges, sex, and vascular disease history. The elements of the CHA2DS2-VASc score are shown below. Because this score contains more elements, it allows greater discrimination of risk, particularly for low risk patients (CHADS2 0-1). Note that it gives one point each for patients age 65-74, history of vascular disease history, and female sex (unless <65 years of age). Thus, although the CHADS2 score of our patient is 0, this likely underestimates her risk of stroke. Note that the CHA2DS2-VASc score in this patient is 3, and the estimated stroke risk is 3.2% per year (compared to 1.9% with CHADS2 = 0). This indicates a "moderate-high" risk. Anticoagulation should be considered in this patient for stroke prevention along with aspirin or clopidogrel for reduction of major adverse cardiovascular events.
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