Antithrombotic Therapy in a Patient With PAD

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?

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