A 72-year-old woman with a history of coronary artery disease (CAD), hypertension, and type 2 diabetes mellitus presents for routine follow-up. Her CAD was managed with a percutaneous coronary intervention (PCI) with a drug-eluting stent to the right coronary artery 18 months ago. She is asymptomatic from a cardiac standpoint. Her medications include aspirin, clopidogrel, rosuvastatin, metformin, and lisinopril. Today, she is diagnosed with new-onset nonvalvular atrial fibrillation. Her heart rate is 88/min and blood pressure is 134/82 mm Hg. Her CHA₂DS₂-VASc score is calculated to be 6.
Which of the following is the most appropriate long-term management plan for this patient's antithrombotic therapy?
- Continue aspirin and clopidogrel; add warfarin.
- Discontinue clopidogrel; continue aspirin and add apixaban. (correct answer)
- Discontinue aspirin and clopidogrel; initiate rivaroxaban.
- Discontinue aspirin; continue clopidogrel and add dabigatran.
Explanation: This patient requires anticoagulation for atrial fibrillation (CHA₂DS₂-VASc score of 6) and is >12 months post-PCI with drug-eluting stent. Current guidelines recommend dual therapy with oral anticoagulation plus single antiplatelet therapy rather than triple therapy to reduce bleeding risk while maintaining ischemic protection. Aspirin is preferred over clopidogrel for the single antiplatelet agent in this setting. Triple therapy (option A) significantly increases bleeding risk and is not recommended for long-term use. Anticoagulation monotherapy (option C) may be considered but combination therapy is more commonly recommended. Option D uses a less optimal antiplatelet choice.