Anticoagulation in an older woman with AF, falls and a bleeding bereavement
An 82-year-old woman attends with her daughter. She has permanent atrial fibrillation diagnosed six years ago, hypertension, and type 2 diabetes. Her medications are aspirin 75 mg daily, bisoprolol 2.5 mg, ramipril 5 mg, and metformin 500 mg twice daily. She lives alone; her daughter calls every day. Four weeks ago she fell in the kitchen, with no injury, but she has been fearful since. Blood pressure is 146/80 mmHg, pulse 78 and irregular. Bloods: haemoglobin 118 g/L, platelets 210 × 10⁹/L, creatinine 142 µmol/L, eGFR 35 mL/min/1.73 m², normal liver function. Weight 52 kg. She has never had a stroke or a significant bleed. She is anxious about anticoagulation because her late husband died after a warfarin-related intracranial bleed. Her daughter asks whether the aspirin is enough to prevent a stroke.
1. Calculate her CHA₂DS₂-VASc and HAS-BLED scores. How would you counsel her about anticoagulation given her fall and her husband's death?
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CHA₂DS₂-VASc is 5: age ≥75 (2), female (1), hypertension (1), diabetes (1). Her annual stroke risk is roughly 7%. HAS-BLED is at least 2 (age >65, antiplatelet); her blood pressure is not >160, so hypertension does not score. A HAS-BLED ≥3 should prompt correction of modifiable factors, not withholding anticoagulation.
Her fall is a marker of frailty, but it is not a contraindication. The absolute annual risk of a major bleed on a DOAC is around 2–3%, against a stroke risk of about 7%, and strokes in AF are often disabling or fatal. Her husband's death on warfarin is a powerful emotional anchor: acknowledge it explicitly, explain that DOACs have a lower intracranial haemorrhage risk than warfarin, and that her age, weight and renal function allow a reduced dose. Use absolute numbers rather than 'increased risk'. Address the fall itself: vision, home hazards, gait and balance, postural blood pressure, bisoprolol, vitamin D and bone health. Offer a shared decision with her daughter present, document the discussion, and revisit if she declines.
2. Which anticoagulant would you choose and at what dose? What would you do about the aspirin? Justify your answer with reference to renal function and monitoring.
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Choose apixaban 2.5 mg twice daily. The reduction criteria are age ≥80 years, weight ≤60 kg, and creatinine ≥133 µmol/L; at least two are required. She meets all three (82 years, 52 kg, creatinine 142 µmol/L). A DOAC is preferred to warfarin here: no INR monitoring, fewer drug and food interactions, and a better intracranial bleeding profile. Confirm renal function is stable and check baseline full blood count and liver function.
Stop the aspirin. It has no role in stroke prevention in atrial fibrillation and adds gastrointestinal and intracranial bleeding risk without extra benefit. If she had established vascular disease this would need re-evaluation, but there is no such indication here. Counsel her to avoid NSAIDs, tell any dentist or doctor she is on an anticoagulant, carry an alert card, and follow the missed-dose instructions. Recheck renal function at least every six months because eGFR is 30–60, and after any acute illness. Consider a proton pump inhibitor only if she has additional gastrointestinal risk, and arrange bone density assessment and calcium/vitamin D.
3. What follow-up and safety-netting would you arrange?
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Review in two to four weeks to confirm she is taking the apixaban correctly, check for bruising or other bleeding, and repeat blood pressure. Arrange a falls assessment through the public health nurse or occupational therapist, a vision check, a home hazard review, and a medication review including bisoprolol and metformin dosing at this eGFR. Discuss vitamin D and a DEXA scan.
Safety-net clearly: black or bloody stools, vomiting blood, unexplained bruising, haematuria, severe headache, or any head injury-even if she feels well-require urgent assessment. Explain that a fall on its own is not a reason to stop the anticoagulant, but a significant bleed needs review. Give written information and ensure her daughter knows what to do out of hours. Document the reasoning, the dose reduction criteria, and her preferences. If she later needs surgery or a dental extraction, plan interruption with the operator rather than stopping the drug ad hoc.