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TIA with atrial fibrillation and carotid stenosis — SCE Geriatric Medicine MCQ

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HardStroke careTIA with atrial fibrillation and carotid stenosisSCE Geriatric Medicine

An 85-year-old man with CKD3 and atrial fibrillation has a transient episode of left arm weakness lasting 20 minutes. CT head shows no haemorrhage; carotid imaging shows 80% right internal carotid stenosis, and ECG confirms AF. He has been taking aspirin but not anticoagulation because of age. What is the most appropriate management?

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Correct answer: D — Start anticoagulation for AF after assessing bleeding risk and address carotid disease through stroke specialist review

AF is a major embolic risk and age alone is not a reason to withhold anticoagulation; bleeding risk assessment should identify modifiable risk factors rather than act as a veto. Symptomatic high-grade carotid stenosis also needs urgent stroke specialist consideration, but aspirin alone does not manage AF-related risk. Long-term dual antiplatelet therapy is not a substitute for anticoagulation in AF. Older patients often have more than one stroke mechanism, so management must address each plausible mechanism.

Reference: NICE NG196; National Clinical Guideline for Stroke 2023