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Atrial Fibrillation-Borderline Risk — ABIM Board MCQ

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HardCardiologyAtrial Fibrillation-Borderline RiskABIM Board

A 46-year-old man with paroxysmal atrial fibrillation and treated hypertension has no diabetes, vascular disease, heart failure or prior stroke. Echocardiography shows marked left-atrial enlargement and ambulatory monitoring shows a 45% AF burden. Which approach is most appropriate for stroke prevention?

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

Reveal the answer and explanation

Correct answer: E — Offer a DOAC after discussing individual stroke and bleeding risks

The best answer is “Offer a DOAC after discussing individual stroke and bleeding risks”. For a man with CHA2DS2-VASc 1, anticoagulation is reasonable rather than mandatory or prohibited. High AF burden and enlarged left atrium can inform the shared decision and favor treatment. Aspirin is not an adequate substitute, and appendage occlusion is not first-line when anticoagulation is feasible.

Reference: 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: https://professional.heart.org/en/science-news/2023-acc-aha-accp-hrs-guideline-for-the-diagnosis-and-management-of-atrial-fibrillation