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Anticoagulation Choice in AF — UKMLA MCQ

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ModerateCardiologyAnticoagulation Choice in AFUKMLAMRCGP AKTPSAMRCP Part 1

A 72-year-old woman with non-valvular atrial fibrillation, hypertension and a previous transient ischaemic attack is starting long-term anticoagulation. She weighs 68 kg, her creatinine clearance is 72 mL/min and liver function is normal. Three years ago, she had a bleeding Helicobacter pylori-positive duodenal ulcer; eradication treatment was successful, healing was confirmed and she has had no recurrent bleeding or anaemia. She takes no NSAID or antiplatelet drug. Which anticoagulation regimen is most appropriate if minimising gastrointestinal bleeding risk is a major consideration?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Apixaban 5 mg twice daily

Apixaban is the best option. She has a strong indication for anticoagulation because of her previous TIA and hypertension, while her ulcer is remote, treated and healed rather than active or recent. Comparative evidence in people with non-valvular AF at high gastrointestinal bleeding risk associates apixaban with less gastrointestinal and major bleeding than rivaroxaban or dabigatran. Her age, weight and renal function do not meet apixaban dose-reduction criteria, so 5 mg twice daily is appropriate. Dabigatran 150 mg and rivaroxaban are associated with less favourable gastrointestinal bleeding profiles. Warfarin is an alternative when a DOAC is unsuitable but is not preferred here. Withholding anticoagulation would expose her to substantial preventable stroke risk; bleeding history should prompt risk-factor modification and monitoring, not automatic exclusion from anticoagulation.

Reference: Lip GYH et al. Comparative safety and effectiveness of oral anticoagulants in patients with non-valvular atrial fibrillation and high risk of gastrointestinal bleeding: a nationwide French cohort study. 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11567525/