Selection of the Appropriate Anticoagulant

You are evaluating a 63-year-old man with a history of paroxysmal atrial fibrillation (AF) in the office. His medical history of notable for hypertension, for which he takes hydrochlorothiazide and lisinopril, and diabetes, for which he takes a metformin. He has no history of congestive heart failure, stroke or transient ischemic attack, kidney or liver disease, or symptomatic peripheral vascular disease. 

On review, he has never been treated for atrial fibrillation. Examination reveals a well-appearing man. The cardiac examination reveals an irregularly irregular rhythm with normal rate and without murmurs, rubs, or gallops. No carotid or abdominal bruits are appreciated. Brisk, even distal pulses are noted in all extremities without brachioradial delay. You note no skin rashes or ecchymoses. Laboratory evaluation from a recent outpatient visit reveals normal serum creatinine, liver function tests, and complete blood count. A 12-lead EKG done in your clinic reveals AF with an average ventricular rate of 78 per minute.

Upon completion of your evaluation, he mentions that he is generally healthy and wants to avoid frequent blood draws and testing if possible. Because he is already taking other medications, he also wants to avoid medications with complicated and/or frequent dosing schedules. 

Which of the following therapies is most appropriate for the patient’s atrial fibrillation?

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