Compared with combination therapy with aspirin and clopidogrel, VKA therapy is expected to result in six fewer nonfatal strokes per 1,000 patients over a 1-year period, anywhere from four fewer to three more nonfatal major extracranial bleeds, and no reduction in all-cause mortality (Table 6). Uncertainty regarding the small net clinical bene t at a CHADS2 score of 1 arises as a result of the limitations of the CHADS2 score in estimating stroke risk and the pos- sibility of declining absolute stroke rates over time. Uncertainty regarding the value of the small net bene t arises from the variability in patient values and preferences and the burden and lifestyle limita- tions associated with adjusted-dose VKA therapy. For patients at intermediate risk of stroke with a CHADS2 score of 1 who are unsuitable for or choose not to take an oral anticoagulant for reasons other than concerns about major bleeding (eg, dif culty maintaining a stable INR, lifestyle limitations of regular INR monitoring, dietary restrictions that are too burdensome, or costs of new anticoagulant drugs that are too high), combination therapy with aspirin and clopidogrel provides additional bene t of stroke reduction at the cost of additional bleeding (ACTIVE A trial) (Table 7). Patients opting for com- bination antiplatelet therapy rather than treatment with an oral anticoagulant should be informed that they are choosing an inferior treatment with regard to stroke prevention. Recommendation 2.1.9. For patients with AF, including those with paroxysmal AF, who are at intermediate risk of stroke (eg, CHADS2 score51), we recommend oral anticoagulation rather than no therapy (Grade 1B). We suggest oral anticoagulation rather than aspirin (75 mg to 325 mg once daily) (Grade 2B) or combination therapy with aspirin and clopidogrel (Grade 2B). 