Atrial fibrillation stroke prevention — CCFP MCQ

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HardChronic disease managementAtrial fibrillation stroke preventionCCFP

A 67-year-old man has newly detected atrial fibrillation. He has hypertension and diabetes. Creatinine clearance is 75 mL/min and there is no valvular disease. He is asymptomatic with heart rate 86 beats per minute. What is the most appropriate next step in management?

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Correct answer: C — Start oral anticoagulation after discussing risks and benefits with the patient

This patient requires oral anticoagulation (OAC) based on his CHADS₂ score of 2. At age 67 with hypertension and diabetes, he meets criteria for anticoagulation per Canadian Cardiovascular Society guidelines. Option D is incorrect: acetylsalicylic acid monotherapy provides only 19% relative stroke risk reduction compared with 64% for anticoagulants and is insufficient for CHADS₂ ≥2. Option B is incorrect: immediate cardioversion is not indicated for asymptomatic, rate-controlled AF; cardioversion is reserved for haemodynamically unstable or severely symptomatic patients. Option E is incorrect: dual antiplatelet therapy has no evidence base in AF and increases bleeding risk. Option A is incorrect: controlled heart rate does not eliminate stroke risk, which depends on the presence of AF itself and comorbid risk factors. Option C correctly identifies that OAC initiation with shared decision-making regarding benefits and risks is the standard of care.

Reference: Canadian Family Physician. 'Approach to Atrial Fibrillation,' Vol. 69, No. 4, April 2023. https://www.cfp.ca/content/cfp/69/4/245.full.pdf; Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010–2020.