Anticoagulation and Antiplatelet Therapy — Viva Defence

Opening statement (SASPOP, delivered aloud)

"Mrs Brooks is an 82-year-old retired teacher with persistent atrial fibrillation and a CHA₂DS₂-VASc score of at least 4, giving her a substantial annual stroke risk — on the background of stage 3 chronic kidney disease and recurrent falls, one injurious. Her anticoagulation was stopped after a fall, converting a managed bleeding risk into an unmanaged stroke risk. Her problems are: cardioembolic stroke risk that is currently untreated; CKD, which constrains agent choice and mandates scheduled renal review; a falls syndrome that needs its own workup and treatment; and a family whose fear of bleeding needs respectful, numerical answering. My goal today is to re-establish safe anticoagulation with the lowest-bleeding agent her kidneys allow, and to treat the falls rather than surrendering to them." [1] [3]

Structured problem list

1. Untreated AF stroke risk — CHA₂DS₂-VASc at least 4 (age, female sex, likely hypertension/vascular history); she belongs on an anticoagulant unless a true contraindication exists [3].
2. Recurrent falls — four in a year with one fracture is a falls syndrome needing diagnosis (orthostatic, sedative, visual, neurological, environmental), not a reason to abandon stroke prevention [1].
3. CKD stage 3 — CrCl about 38 mL/min: within DOAC range but excluding dabigatran at borderline renal clearance and mandating periodic renal monitoring [5].
4. Bleeding-risk modifiers — age and prior fall-related injury; address modifiable HAS-BLED items rather than treating the score as a veto [4].
5. Family anxiety and a fragmented medication story — needs shared decision-making with honest numbers and written plans.

Integrated management plan

• Restart anticoagulation — the indication persists and the evidence says the stroke risk dominates: the classic analysis found an AF patient must fall hundreds of times per year before fall-related haemorrhage offsets warfarin's stroke benefit, and DOACs widen that margin by halving intracranial bleeding [1] [2].
• Agent choice: apixaban 5 mg twice daily (2.5 mg bd only if she meets two of the dose-reduction criteria — age 80+, weight 60 kg or less, creatinine 133 or over; at creatinine 118 she does not) — best GI bleeding profile in ARISTOTLE, least renal clearance of the class, and suited to CrCl 38. I would avoid dabigatran (about 80% renally cleared) at this renal function and in an 82-year-old with falls [2] [5].
• Treat the falls in parallel: medication review for sedatives and antihypertensives, lying-and-standing blood pressure, vision, gait and balance assessment, strength-and-balance programme referral, home hazard review, and bone protection after her Colles fracture.
• Modify bleeding risk: blood pressure to target, no NSAIDs, no added aspirin, alcohol review, and PPI only if a GI indication emerges [4].
• Surveillance schedule: renal function and FBC at least 6–12 monthly and after any intercurrent illness; a documented plan for surgery (hold 24–48 hours by bleed risk) and for any future bleed (reversal exists, resumption is planned — not permanent cessation).
• Communication: written information for the family, a missed-dose plan, and a review appointment — adherence is the treatment when half-lives are short.

Probing questions with model answers

"She has fallen four times. Why are you willing to anticoagulate her at all?" — "Because the arithmetic is not close. Her annual stroke risk untreated is several per cent; the Man-Son-Hing analysis showed a patient must fall on the order of 300 times per year before the bleeding cost of warfarin outweighs its stroke benefit, and apixaban halves the intracranial bleeding rate compared with warfarin. Falls tell me to work on falls — they do not convert her stroke risk into an acceptable one" [1] [2].

"Why apixaban rather than warfarin — warfarin is easier to monitor in someone you are worried about." — "Monitoring is not the same as safety. Warfarin's intracranial haemorrhage rate is roughly double the DOAC rate, and in an 82-year-old who falls, that is the number that matters. Her renal function still supports apixaban with a standard dose; I will watch her creatinine and switch strategy if it declines below the DOAC thresholds" [2].

"Why not dabigatran — it was superior to warfarin in RE-LY." — "RE-LY's 150 mg dose was superior for stroke prevention, but dabigatran is about 80% renally cleared, accumulates when the kidneys fail, and carries a GI bleeding signal at that dose. In an 82-year-old with a CrCl of 38, apixaban's pharmacology is simply a better fit" [5] [2].

"Her daughter asks: if she bleeds badly, can it be undone?" — "Yes. For apixaban we have andexanet alfa, and prothrombin complex concentrate as a pragmatic alternative — but I would frame it honestly: reversal is for life-threatening bleeding, it carries a thrombotic cost, and the commonest bleeds are managed by stopping the drug and supporting haemostasis. I would rather she fears a preventable stroke more than a treatable bleed" [2].

"What would make you stop the anticoagulant?" — "A short list, written down: a second major bleed without a treatable source; renal decline below the DOAC thresholds prompting reassessment of the whole strategy; or a goals-of-care conversation in which prevention horizons no longer match her wishes. A fall is not on that list — a fall triggers falls work, not deprescribing" [1].

Communication points

• Use absolute numbers with the family: strokes prevented versus bleeds caused per 100 patients per year, and what each event actually looks like [1].
• Document the shared decision and the specific circumstances in which therapy would be revisited — this protects the plan from reflex cessation at the next fall or admission.
• Give the missed-dose rule and the interaction rules in writing; the drug only works if it is taken.