CASE SCENARIO

JB is a 78-year-old man with a history of paroxysmal atrial fibrillation (AF), hypertension, hyperlipidemia, and degenerative joint disease of the spine and hips necessitating the use of a cane. He comes to you, his primary care physician, for a follow-up visit after consulting with a cardiologist in the emergency department.

JB previously was taking warfarin for stroke prevention, but he was switched to the direct oral anticoagulant (DOAC) apixaban (Eliquis) after several episodes of epistaxis associated with an elevated international normalized ratio. He was doing well until 1 month ago, when he had to go to the emergency department with multiple contusions after a fall. He did not have a head injury, and results of computed tomography of the brain were normal. He was instructed by the emergency department physician to continue the apixaban and to follow up with you.

You have a detailed shared decision-making discussion with JB, including a review of his CHA₂DS₂-VASc (congestive heart failure, hypertension, age 75 years or older, diabetes, stroke/transient ischemic attack/thromboembolism, vascular disease, age 65–74 years, sex category) score and estimated risk of embolic stroke. You decide to discontinue apixaban because the bleeding risk outweighs the benefits. JB tells you that the cardiologist who consulted in the emergency department suggested that JB could take aspirin or clopidogrel instead of apixaban. He asks you about that today.