A 78-Year-Old Man Comes to the Office for Routine Follow-Up

A 78-year-old man comes to the office for routine follow-up.  He had an ischemic stroke 8 months ago and has some residual weakness in his left leg.  The patient had a fall 4 months ago without significant injuries, but his gait is somewhat unsteady.  Medical history is significant for diet-controlled type 2 diabetes mellitus, hypertension, chronic kidney disease, and persistent atrial fibrillation.  Current medications are lisinopril, metoprolol, atorvastatin, and low-dose aspirin.  The patient has been treated with warfarin due to atrial fibrillation, but he found it difficult to follow frequent blood checks and stopped the therapy.  He is a lifelong nonsmoker and does not drink alcohol.  Despite leg weakness, he enjoys short walks in his yard every morning.
Blood pressure is 133/76 mm Hg, and pulse is 88/min and irregular.  No murmurs are heard on cardiac auscultation, and there is no peripheral edema.
Laboratory results are as follows:
Estimated glomerular filtration rate (eGFR) is 39 mL/min.  ECG shows atrial fibrillation and voltage criteria for left ventricular hypertrophy.
Which of the following is the best therapy to offer this patient?

A) Aspirin monotherapy due to a favorable benefit/risk ratio
B) No antithrombotic therapy because the risks significantly outweigh the benefits
C) Oral factor Xa inhibitor due to a favorable benefit/risk ratio
D) Warfarin therapy because of history of chronic renal disease
E) Warfarin therapy because of the risk of falls

Correct Answer:

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