New Paradigms in the
Science and Medicine of Heart Disease
New Frontiers in Stroke Prevention for
Atrial Fibrillation
Focus on Evolving Strategies for Initial Assessment, Risk
Stratification, Monitoring, and Pharmacologic Interventions
for Stroke Prevention in Atrial Fibrillation (SPAF)
Program Chairman
Allan V. Abbott, MD
Program Chair and Moderator
Professor of Clinical Family Medicine
Associate Dean of Continuing Medical Education
Keck School of Medicine
University of Southern California
Program Faculty
Allan V. Abbott, MD
Scott Kaatz, DO, MSc, FACP
Program Chair and Moderator
Professor of Clinical Family Medicine
Associate Dean of Continuing Medical
Education
Keck School of Medicine
University of Southern California
Los Angeles, California
Clinical Associate Professor of Medicine
Associate Residency Program Director
Department of Medicine
Director, Anticoagulation Clinics
Henry Ford Hospital
Detroit, Michigan
Alan K. Jacobson, MD, FACC
Associate Professor of Medicine
Medical Director
Heart Center for Women
Rush University Medical College
Chicago, Illinois
Assistant Professor
Loma Linda University School of
Medicine
Director, Anticoagulation Services
Associate Chief of Staff for Research
Loma Linda Veterans Affairs Medical
Center
Loma Linda, California
Annabelle S. Volgman, MD, FACC
New Paradigms in the
Science and Medicine of Heart Disease
New Frontiers in Stroke Prevention for
Atrial Fibrillation
Focus on Evolving Strategies for Initial Assessment, Risk
Stratification, Monitoring, and Pharmacologic Interventions
for Stroke Prevention in Atrial Fibrillation (SPAF)
Program Chairman
Allan V. Abbott, MD
Program Chair and Moderator
Professor of Clinical Family Medicine
Associate Dean of Continuing Medical Education
Keck School of Medicine
University of Southern California
A Brief History
► 1628, William Harvey was probably the first to
describe "fibrillation of the auricles" in animals.
► 1785 William Withering recorded digitalis leaf
brought some relief to patients with severe
heart failure.
► 1900, Sir Thomas Lewis in London was the first
to record an electrocardiogram in a patient with
atrial fibrillation.
► However the exact mechanisms and importance
remained controversial until the 1970s.
Epidemiology of Atrial Fibrillation
► Atrial fibrillation is fairly uncommon in people
under 50 years but is found in 0.5% of people
aged 50-59, increasing to 8-8% at age 80-89.
► Atrial fibrillation may be either chronic or
paroxysmal.
► In the Framingham study, hypertension, cardiac
failure, and rheumatic heart disease were the
commonest precursors of atrial fibrillation.
► About a third of patients have idiopathic or
"lone" atrial fibrillation - no precipitating cause
can be identified and no evidence of structural
heart disease exists.
Treatment, A Brief History
► 1982, The epidemiological importance of atrial
fibrillation as an important precursor of cardiac
and cerebrovascular death was investigated by
William Kannell and colleagues.
► 1980s-1990s, awareness increased of the
hazards of sustained atrial fibrillation and the
benefits of prophylaxis against thrombosis in
preventing stroke.
► Early treatment was electrical or chemical
cardioversion, digitalis for rate control, and
warfarin or aspirin for prevention of
thromboemboli.
Treatment, Last Decade
► Rate control with beta-blockers and/or
calcium channel blockers (digoxin or
amiodarone if CHF)
► Cardioversion, heparin and electrical or
chemical cardioversion then warfarin
► Warfarin with its associated risk of bleeding
and requirement for frequent monitoring
remains standard today
Treatment, Evolving Paradigms
New treatments
► End the atrial fibrillation with catheter
ablation or surgical approaches
► Replace warfarin with novel oral
anticoagulants ablate
Treatment, Evolving Paradigms
Ablation Procedures
Treatment, Evolving Paradigms
Novel oral anticoagulants
New Paradigms in the
Science and Medicine of Heart Disease
Epidemiology, Risk Stratification, and
Individualized Therapy in
Atrial Fibrillation
Aligning Stroke-Preventing Strategies with
Appropriate Patient Subgroups
Annabelle S. Volgman, MD FACC
Associate Professor of Medicine
Medical Director, Heart Center for Women
Rush University Medical Center
Chicago, IL
Outline
►
Epidemiology, risk stratification, and
individualized therapy in atrial fibrillation
●
►
Aligning stroke-preventing strategies with
appropriate patient subgroup
The Role of Risk Stratification for Identifying
Antithrombotic Strategies for Stroke
Prevention:
●
Evidence-based options for the family medicine
specialist at the front lines of care
ATRIA: Prevalence of atrial fibrillation increases
with age
12
10
8
Prevalence
6
(%)
4
2
0
<55
55-59
Women (n = 7801)
60-64
65-69
70-74
Age (years)
75-79
80-84
≥85
Men (n = 10,173)
Go AS et al. JAMA. 2001;285:2370-5.
Prevalence of AF in Adults Aged 65-84
Years (% of Total Population), 1968-1989
19681970
19711973
19751977
19791981
19831985
19871989
Men
3.2
5.3
6.5
7.8
7.5
9.1
Women
2.8
3.3
4.3
4.3
3.9
4.7
Adults
Pilote, L. et al. CMAJ 2007;176:S1-S44
Atrial Fibrillation: Framingham Study
AF Prevalence
(%)
Strokes Attributable
to AF (%)
50-59
0.5
6.5
60-69
1.8
8.5
70-79
4.8
18.8
80-89
8.8
30.7
Age
Wolf PA et al. Stroke. 1991;22-983-8.
Lifetime Risk of Developing AF
►
40 years old
●
●
►
Men
Women
●
●
80 years old
●
●
Men
Women
●
●
26%
23%
23%
22%
The lifetime risk for AF was approximately 16% in the absence
of a history of congestive heart failure or myocardial infarction.
Lloyd-Jones DM et al. Circulation 2004.
Factors that Affect Developing
Primary Atrial Fibrillation
Factor
Study
Effect
Obesity/MS/DM
VALUE
Increase
1
Alcohol
WHS
Statins
Multiple
3
Decrease
ACE-I/ARBs
Multiple
4
Decrease
Fish/Fish oils
Multiple
5
Decrease (post-op)
Vitamin E
WHS
Increase
2
6
No effect
Aksnes TA et al. Am J Cardiol. 2008 Mar 1;101(5):634-8 2 Conen, D et al. JAMA Dec 2008, 300 (21):2489-96.
3 Faucier L et al. J Am Coll Cardiol, 2008; 51:828-835, 4 Healey et al. J Am Coll Card, 2005: 45:1832-1839,
5 Cheng W et al. J Altern Complement Med. 2008 Oct;14(8):965-74. 6 Ganz LI et al. Heart Rhythm 2008.
1
Stroke Risk Increases with Age
Gender Differences in the Risk of Ischemic
Stroke and Peripheral Embolism in AFib
The AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) Study
Fang,MC et al. Circulation. 2005;112:1687-1691
Copenhagen City Heart Study
►
The independent effect of AF on stroke rate was
4.6-fold greater in women than in men:
●
●
►
Hazard ratio in women 7.8 (95% CI, 5.8 to 14.3)
Hazard ratio in men 1.7 (95% CI, 1.0 to 3.0)
The independent effect of AF on the
cardiovascular mortality rate was 2.5-fold
greater in women than in men:
●
●
Hazard ratio in women 4.4 (95% CI, 2.9 to 6.5)
Hazard ratio in men 2.2 (95% CI, 1.6 to 3.1)
Friberg J et al. American Journal of Cardiology 2004; 94: 889-894
Patients Older than 75 Years Less likely
to Receive Therapy for CV Events
►
Patients older than 75 years of age
●
►
<50% chance of receiving clinically proven
treatments for cardiovascular events such
as MI and atrial fibrillation as compared to
younger patients.
Conclusion: The study results suggest that
physicians need to be more aware of and
willing to use indicated treatments in the
elderly.
Ganz DA et al.Journal of the American Geriatric Society 1999; 47: 145-150
Risk Factors of Ischemic Stroke & Systemic Embolism
in Patients with Nolvalvular Atrial Fibrillation
Risk Factors
Relative Risk
Previous stroke or TIA
2.5
Diabetes mellitus
1.7
History of hypertension
1.6
Heart failure
1.4
Advanced age (continuous,
per decade)
1.4
AHA/ACC/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation.
Circulation, JACC and Europace, 2006.
Stroke Risk with Nolvalvular AF Not Treated with
Anticoagulation According to the CHADS2 Index
CHADS2 Risk Criteria
Score
Previous stroke or TIA
2
Age > 75 years
1
Hypertension
1
Diabetes mellitus
1
Heart failure
1
Patients
(N = 1733)
Adjusted Stroke Rate (%/y)
(95% CI)
CHADS2 Score
120
1.9 (1.2 to 3.0)
0
463
2.8 (2.0 to 3.8)
1
523
4.0 (3.1 to 5.1)
2
337
5.9 (4.6 to 7.3)
3
220
8.5 (6.3 to 11.1)
4
65
12.5 (8.2 to 17.5)
5
5
18.2 (10.5 to 27.4)
6
AHA/ACC/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation.
Circulation, JACC and Europace, 2006.
Risk Stratification Schemes Use to Predict
Thromboembolism with Nonvalvular AF
Fang MC et al. JACC 2008, 51(6):810-15.
Annual TE Rates Across Risk Groups Using 5 Risk
Stratification Schemes Used to Predict AF-Related TE
Fang MC et al. JACC 2008, 51(6):810-15.
New Frontiers for Stroke
Prevention in Atrial Fibrillation
Annabelle S. Volgman, MD FACC
Associate Professor of Medicine
Medical Director, Heart Center for Women
Rush University Medical Center
Chicago, IL
Meta-analysis of Stroke Prevention for
High Risk Atrial Fibrillation Trials
►
Adjusted dose warfarin
●
●
►
Antiplatelet therapy
●
►
Stroke Risk Reduction – 60%
Death Risk Reduction – 25%
Stroke Risk Reduction – 20%
Advantage of warfarin over antiplatelet therapy
●
Stroke Risk Reduction– 40%
Hart R, Pearce L, Aguilar M. Annals of Internal Medicine. June 2007,146:857-67.
Analysis of 5 Antithrombotic Trials
►
Women > 75 years were 54% less likely to
receive warfarin and twice as likely to receive
aspirin
►
Warfarin reduced stroke risk by 84% in women
and 60% in men
►
ASA resulted in significantly decreased stroke
risk in men (44%) but not in women (23%)
Pilote L, CMAJ. 2007; 176(6):S1-44.
Physician and Patient Reluctance
►
CARAF* demonstrated that women on
warfarin were 3.35 times more likely to
experience major bleeding.
►
Nine of ten women who experienced
major bleeds were < 75 years old.
►
INRs at time of bleeding were elevated,
but the levels were similar in men and
women.
* Canadian Registry of Atrial Fibrillation
Humphries KH et al. Circulation. 2001; 103:2365-70
AHA/ACC/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation.
Circulation, JACC and Europace, 2006.
Bleeding Risks
►
SPORTIF Trial
►
Anticoagulation and
Risk Factors in Atrial
Fibrillation (ATRIA)
Study
►
Stroke Prevention in
Atrial Fibrillation (SPAF)
studies
►
Women > Men (p=0.001minor; p=NS
major/minor)
►
1.0% for women versus
1.1% for men
►
Annual bleeding rates
were 1.5%, 1.7% and
2.1% both genders
Gomberg-Maitland M, Wenger NK, Feyzi J, Lengyel M, Volgman AS, Petersen P, Frison L, Halperin JL. Eur
Heart J. 2006; 27:1947-53. Fang MC, et al. Circulation. 2005; 112:1687-91. Lancet. 1996; 348:633-8.
Summary
►
Individualize anticoagulation therapy for patients
with atrial fibrillation
►
Low risk patients should be treated with aspirin
►
Intermediate to high risk patients benefit from
anticoagulation but bleeding risks may offset
benefit
►
If bleeding risk is minimized, intermediate risk
patients would have improved risk/benefit ratio
from anticoagulation
New Paradigms in the
Science and Medicine of Heart Disease
The Emerging Role of Direct Thrombin
and Factor Xa Inhibition for Thrombosis
Reduction in Heart Disease
Mechanisms and Recent Clinical Trials
Scott Kaatz, DO, MSc, FACP
Clinical Associate Professor of Medicine
Associate Residency Program Director
Department of Medicine
Director, Anticoagulation Clinics
Henry Ford Hospital
Detroit, Michigan
The Emerging Role of Direct Thrombin and Factor Xa
Inhibition for Thrombosis Reduction in Heart Disease
Mechanisms and Recent Clinical Trials
►
Anticoagulant options in atrial fibrillation
►
Warfarin
►
Dabigatran
►
Apixaban
►
Rivaroxaban
Stroke Rate per Year with Different
Antithrombotic Options in AF
Option
Approximate
Rate/Year
Hart
ACTIVE W
No treatment
4.5%
4.5%
Thrombin
ASA
3.5%
3.2%
Yes
3.3%
ASA +
Clopidogrel
2.5%
2.4%
2.4%
Warfarin
1.5%
Apixaban
1.5%
Dabigatran 110
1.5%
1.4%
Dabigatran 150
1.0%
1.0%
1.8%
ACTIVE A AVERROES
3.3%
1.4%
Hart RG. Ann Intern Med. 2007 Jun 19;146(12):857-67. PMID: 17577005
Connolly S. Lancet. 2006 Jun 10;367(9526):1903-12. PMID: 16765759
Connolly SJ. N Engl J Med. 2009 May 14;360(20):2066-78. PMID: 19336502
Connolly S. Hotline session at ESC 8.31.10
Connolly SJ. N Engl J Med. 2009 Sep 17;361(12):1139-51. PMID: 19717844
RELY
1.6%
1.5%
Comparative Pharmacology
Characteristic
Apixaban
Rivaroxaban
Dabigatran
Target
Factor Xa
Factor Xa
Thrombin
Prodrug
No
No
Yes
Bioavailability
60%
80%
6%
Dosing
Fixed, b.i.d.
Fixed, o.d.
Fixed, o.d./bid
Half life
12 hours
7 to 11 hours
12-17 hours
Renal clearance
Routine coag.
monitoring
25%
35%
80%
No
No
No
Potent CYP3A4 &
P-gp inhibitors
Potent CYP3A4 &
P-gp inhibitors
Potent P-gp
inhibitors
Drug interactions
Courtesy of John Eikelboom
The Emerging Role of Direct Thrombin and Factor Xa
Inhibition for Thrombosis Reduction in Heart Disease
Mechanisms and Recent Clinical Trials
►
Anticoagulant options in AF
►
Warfarin
►
Dabigatran
►
Apixaban
►
Rivaroxaban
Warfarin
http://www.anaesthesia
uk.com/images/clotting
_cascade.gif
Warfarin
• Warfarin was launched as the ideal rat poison in
1948. Although it was thought at first to be too toxic
for human use
►
In 1951 the failed attempted suicide of a
navy recruit who had taken a large dose
of rat poison led clinicians to discard
dicumarol in favor of warfarin.
►
The first clinical study with warfarin was
reported in 1955. In the same year,
President Eisenhower was treated with
warfarin following a heart attack
Scully. The Biochemist, Feb 2002 http://www.biochemist.org/bio/02401/0015/024010015.pdf
Warfarin vs. no Treatment
or Placebo
Hart RG. Ann Intern Med. 2007 Jun 19;146(12):857-67. PMID: 17577005
The Emerging Role of Direct Thrombin and Factor Xa
Inhibition for Thrombosis Reduction in Heart Disease
Mechanisms and Recent Clinical Trials
►
Anticoagulant options in AF
►
Warfarin
►
Dabigatran
►
Apixaban
►
Rivaroxaban
Direct
Thrombin
Inhibitors
http://www.anaesthesia
uk.com/images/clotting
_cascade.gif
Medicinal Leech
(Hirudo Medicinalis)
•Scientific interest in leeches date back to ancient India
•However, the first Western citation is credited to the Greek, Nicander of
Colophon (130 BC)
•This therapeutic use of leeches, the medicinal leech in particular,
reached a height between 1825 and 1840.
•A more contemporary use of leeches
was discovered in 1957 by Markwardt
•The leech secretion hirudin was
isolated and subsequently its
anticoagulant properties with respect to
the elucidation of blood clotting
mechanisms were examined.
http://soma.npa.uiuc.edu/courses/physl490b/models/leech_swimming/leech_swim.html
RELY Trial
►
►
►
►
►
►
►
Question: Is Dabigatran oral unmonitored direct thrombin
inhibitor as effective and safe as warfarin for stroke
prevention in AF?
Design: Randomized trial, warfarin was un-blinded
Patients: 18,113 AF patients with at least on stroke risk
factor
Interventions:
● Dabigatran 110 mg bid
● Dabigatran 150 mg bid
Comparison: Warfarin, INR 2.0-3.0
Primary outcome: Stoke and systemic embolism
Timeframe: Mean follow up was 2.0 years
Connolly SJ. N Engl J Med. 2009 Sep 17;361(12):1139-51. PMID: 19717844
RELY
Connolly SJ. N Engl J Med. 2009 Sep 17;361(12):1139-51. PMID: 19717844
RELY
Connolly SJ. N Engl J Med. 2009 Sep 17;361(12):1139-51. PMID: 19717844
RELY
Connolly SJ. N Engl J Med. 2009 Sep 17;361(12):1139-51. PMID: 19717844
The Emerging Role of Direct Thrombin and Factor Xa
Inhibition for Thrombosis Reduction in Heart Disease
Mechanisms and Recent Clinical Trials
►
Anticoagulant options in AF
►
Warfarin
►
Dabigatran
►
Apixaban
►
Rivaroxaban
AVERROES
►
Question: Is apixaban superior to ASA in
patients with AF who are not candidates for
warfarin?
►
Design: RCT, double blinded
►
Patients: AF patients not candidates for warfarin
►
Intervention: apixaban 5 mg (2.5 mg) bid
►
Comparison: ASA 81-325 mg qd
►
Outcome: stroke or systemic embolism
Connolly S. Hotline, ESC, 8.31.10
Connolly S. Hotline, ESC, 8.31.10
Connolly S. Hotline, ESC, 8.31.10
Connolly S. Hotline, ESC, 8.31.10
The Emerging Role of Direct Thrombin and Factor Xa
Inhibition for Thrombosis Reduction in Heart Disease
Mechanisms and Recent Clinical Trials
►
Anticoagulant options in AF
►
Warfarin
►
Dabigatran
►
Apixaban
►
Rivaroxaban
ROCKET
►
►
►
►
►
►
Question: is rivaroxaban non-inferior to warfarin for
stroke prevention in AF
Design: RCT, double blinded
Patients: AF and CHADS2 > 2
Intervention: rivaroxaban 20 mg qd
Comparison: warfarin
Outcome:
●
●
►
Stroke and systemic embolism
Major and non-major clinically relevant bleeding
Result expected to be presented at AHA, November 2010
www.clinicaltrials.gov NCT00403767
The Emerging Role of Direct Thrombin and Factor Xa
Inhibition for Thrombosis Reduction in Heart Disease
Mechanisms and Recent Clinical Trials
►
Anticoagulant options in AF
►
Warfarin
►
Dabigatran
►
Apixaban
►
Rivaroxaban
New Paradigms in the
Science and Medicine of Heart Disease
Optimizing Stroke Prevention in AF
with Established and Currently
Available Therapies
The Role of Vitamin K Antagonists –
What Works? What Doesn’t?
Alan K. Jacobson, MD
Director, Anticoagulation Services
Loma Linda VA Medical Center
Loma Linda, California
Why do we need another warfarin
management lecture?
►
Warfarin therapy is:
●
●
●
●
Highly effective
Complex to manage
Underutilized
When utilized, managed poorly
… but effective solutions have evolved.
Blood Flow in Atrial Fibrillation
Disturbed Flow
(left atrium)
Stroke Risk
Warfarin in Prospective AF Trials
Intention-to-treat analysis
Stroke Rate (%/year)
8
Control
Warfarin
7.0
6
4
4.6
4.3
3.6
3.0
2.3
2
1.9
0
person-years
p value
AFASAK
825
p=0.03
2.1
0.4
SPAF
504
p=0.01
Adapted from Atwood, Albers, Herz 1993;18:27-38
BAATAF
922
p=0.002
0.9
CAFA
490
p>0.2
SPINAF
896
p=0.001
Anticoagulant Therapy is Effective
RR
79%
83%
Loma Linda VA Medical Center, 2010
83%
73%
79%
83%
Anticoagulation of AF
Risk — Benefit
X
OR
vs.
Oral Anticoagulation - Challenges
►
Narrow therapeutic dosing range
●
►
Variable dosage requirement
●
●
●
►
10-15% dosing window
Effect of medications
Effect of diet
Effect of liver function
Serious consequences if dosing wrong
Burdens of Anticoagulation
►
Restricted diets - NOTHING green, NO
Vitamin K
►
Restricted medications - NO aspirin, NO
NSAIDS
►
Ongoing need for blood tests to check
PT/INR
►
Burdens affect patients and providers
►
Clinical practice has often been driven more
by tradition than science
Burdens of Anticoagulation
►
Solutions:
●
●
●
●
Diet - CONSISTENT Vitamin K intake
Drug interactions - CONSISTENT if NECESSARY
Minimal need for restrictions, in fact, some may
benefit from supplementation
Prothrombin time testing and management…. ??
Systematic Anticoagulation
Management
Direct Active Management
by Qualified Health Care Provider
Ongoing Patient Education
Ongoing QI
Patient-specific
Decision Support
and Interaction
Patient Scheduling
and Tracking
Accessible, Accurate, and
Frequent PT/INR
Testing
Enabling Technologies: POC testing, computerization
Quality Question
Are you able to identify, on an
ongoing basis, which patients are
overdue for testing?
Active vs. Passive
Management
Patients Assigned to Warfarin in AF Trials
Intensity of Anticoagulation When Stroke Occurred
1.8
4.0
1.7
1.6
3.0
INR
PT
1.5 Ratio
1.4 (ISI 2.4)
1.3
1.2
1.1
1.0
Ratio
2.0
1.0
AFASAK
CAFA
SPAF I
BAATAF
SPINAF
ACCP recommendations: INR 2.0–3.0
Target range for individual study
Petersen et al. Lancet 1989:171–75
SPAF. Circ 1991;84:527–39
BAATAF. N Engl J Med 1990; 323:1505–11
Connolly et al. J Am Coll Cardiol 1991;18:349–55
Ezekowitz et al. N Engl J Med 1992;327:1406–12
Hirsh, Dalen, Deykin, Poller. CHEST 1992;312S–326S
PERCEIVED INR Therapeutic Range
Bleed
Risk
Clot
Risk
1
2
7
3
4
INR Intensity
5
6
Incidence per 100 Patient-Years
ACTUAL
INR therapeutic range
100
80
60
40
20
0
INR
INR-Specific Incidence of All Adverse Events (All Episodes of
Thromboembolism, All Major Bleeding Episodes, and Unclassified Stroke).
Cannegeiter et al The dotted lines indicate the 95 percent confidence interval.
Incidence Rates of Ischemic Stroke
and Intracranial Hemorrhage
Adapted from Hylek EM, et al. N Engl J Med. 2003;349:1019-1026.
Recommended Range for Warfarin
Therapy For Patients in Atrial Fibrillation
►Target:
INR 2.5
►Range: INR 2.0–3.0
CHEST 1998;114:579s-589s
Methods of Monitoring - Options
►
Central Laboratory Testing with Professional
Management of Results
►
Point-of-Care Testing (Professional) with
Professional Management of Results
►
Point-of-Care Testing (Patient) with Patient or
Professional Management
Which is best???
Different solutions for different patients in
different settings
Why do we need another warfarin
management lecture?
►
Warfarin therapy is:
●
●
●
●
Highly effective
Complex to manage
Underutilized
When utilized, managed poorly
… but effective solutions have evolved.
Progress of Medicine
►
Out of the enormous number of medicinal agents brought under
our notice by puffing advertisements in the press, medical as well
as lay, by pamphlets or even large books delivered by post, or by
actual 'specimens for trial' which are nowadays so liberally
delivered at our residences, comparatively few hold their ground,
or stand a fair and candid criticism and investigation of their
vaunted merits. Still a certain proportion do and I see every
reason to anticipate that, as the result of the systematic
researches, scientific and practical, now carried on in so many
laboratories, valuable additions will be made from time to time to
the medicinal agents at our disposal for the help and comfort of
our patients. I only hope that in our love for the new we will not
entirely throw out old friends which have done real and effective
service in the past and are today as deserving of our regard as
ever
(Lancet 1899, Dr. F. Roberts).
Progress of Medicine
►
►
Out of the enormous number of medicinal agents brought under
our notice by puffing advertisements in the press, medical as well
as lay, by pamphlets or even large books delivered by post, or by
actual 'specimens for trial' which are nowadays so liberally
delivered at our residences, comparatively few hold their ground,
or stand a fair and candid criticism and investigation of their
vaunted merits. Still a certain proportion do and I see every reason
to anticipate that, as the result of the systematic researches,
scientific and practical, now carried on in so many laboratories,
valuable additions will be made from time to time to the medicinal
agents at our disposal for the help and comfort of our patients.
I only hope that in our love for the new we will
not entirely throw out old friends which have
done real and effective service in the past and
are today as deserving of our regard as ever.
The Future
►
Refined management of the old drug –
warfarin
►
Variety of new agents with predictable
therapeutic ranges and improved risk benefit
but with continued need for education,
hemorrhagic risk assessment, and monitoring
►
Improved range of options to facilitate stroke
prevention in patients with atrial fibrillation