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Title: Advanced Practice Nursing in Acute and Critical Care Environments: National ACNP Study


1
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2
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

3
Program Faculty
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   Annabelle S. Volgman, MD,
FACC Associate Professor of Medicine Medical
Director Heart Center for Women Rush University
Medical College Chicago, Illinois
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 Los Angeles,
California   Alan K. Jacobson, MD, FACC 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  
4
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

5
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.

6
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.

7
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.

8
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

9
Treatment, Evolving Paradigms
  • New treatments
  • End the atrial fibrillation with catheter
    ablation or surgical approaches
  • Replace warfarin with novel oral anticoagulants
    ablate

10
Treatment, Evolving Paradigms
Ablation Procedures
11
Treatment, Evolving Paradigms
  • Novel oral anticoagulants

12
Epidemiology, Risk Stratification, and
Individualized Therapy in Atrial Fibrillation
Aligning Stroke-Preventing Strategies with
Appropriate Patient Subgroups
New Paradigms in the Science and Medicine of
Heart Disease
  • Annabelle S. Volgman, MD FACC
  • Associate Professor of Medicine
  • Medical Director, Heart Center for Women
  • Rush University Medical Center
  • Chicago, IL

13
Outline
  • Epidemiology, risk stratification,
    andindividualized therapy in atrial fibrillation
  • Aligning stroke-preventing strategies
    withappropriate patient subgroup
  • The Role of Risk Stratification for
    IdentifyingAntithrombotic Strategies for Stroke
    Prevention
  • Evidence-based options for the family
    medicinespecialist at the front lines of care

14
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15
Prevalence of AF in Adults Aged 65-84 Years ( of
Total Population), 1968-1989
Adults 1968-1970 1971-1973 1975-1977 1979-1981 1983-1985 1987-1989
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
Pilote, L. et al. CMAJ 2007176S1-S44
16
Atrial Fibrillation Framingham Study
Age 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
Wolf PA et al. Stroke. 199122-983-8.
17
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.
18
Factors that Affect Developing Primary Atrial
Fibrillation
Factor Study Effect
Obesity/MS/DM VALUE 1 Increase
Alcohol WHS 2 Increase
Statins Multiple 3 Decrease
ACE-I/ARBs Multiple 4 Decrease
Fish/Fish oils Multiple 5 Decrease (post-op)
Vitamin E WHS 6 No effect
1 Aksnes TA et al. Am J Cardiol. 2008 Mar
1101(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 51828-835, 4 Healey et al. J Am
Coll Card, 2005 451832-1839, 5 Cheng W et al.
J Altern Complement Med. 2008 Oct14(8)965-74.
6 Ganz LI et al. Heart Rhythm 2008.
19
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20
Stroke Risk Increases with Age
21
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. 20051121687-1691
22
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
23
Patients Older than 75 Years Less likely to
Receive Therapy for CV Events
  • Patients older than 75 years of age
  • lt50 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
24
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.
25
Stroke Risk with Nolvalvular AF Not Treated with
Anticoagulation According to the CHADS2 Index
CHADS2 Risk Criteria Score
Previous stroke or TIA 2
Age gt 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.
26
Risk Stratification Schemes Use to Predict
Thromboembolism with Nonvalvular AF
Fang MC et al. JACC 2008, 51(6)810-15.
27
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.
28
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29
Meta-analysis of Stroke Prevention for High Risk
Atrial Fibrillation Trials
  • Adjusted dose warfarin
  • Stroke Risk Reduction 60
  • Death Risk Reduction 25
  • Antiplatelet therapy
  • 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 2007,146857-67.
30
Analysis of 5 Antithrombotic Trials
  • Women gt 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.
31
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 lt 75 years old.
  • INRs at time of bleeding were elevated, but the
    levels were similar in men and women.

Canadian Registry of Atrial Fibrillation Humphr
ies KH et al. Circulation. 2001 1032365-70
32
AHA/ACC/ESC 2006 Guidelines for the Management of
Patients with Atrial Fibrillation. Circulation,
JACC and Europace, 2006.
33
Bleeding Risks
  • SPORTIF Trial
  • Anticoagulation and Risk Factors in Atrial
    Fibrillation (ATRIA) Study
  • Stroke Prevention in Atrial Fibrillation (SPAF)
    studies
  • Women gt Men (p0.001- minor pNS 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 271947-53. Fang MC, et al.
Circulation. 2005 1121687-91. Lancet. 1996
348633-8.
34
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

35
The Emerging Role of Direct Thrombin and Factor
Xa Inhibition for Thrombosis Reduction in Heart
Disease Mechanisms and Recent Clinical Trials
New Paradigms in the Science and Medicine of
Heart Disease
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  
36
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

37
Stroke Rate per Year with Different
Antithrombotic Options in AF
Option Approximate Rate/Year Hart ACTIVE W ACTIVE A AVERROES RELY
No treatment 4.5 4.5 Thrombin
ASA 3.5 3.2 Yes 3.3 3.3
ASA Clopidogrel 2.5 2.4 2.4
Warfarin 1.5 1.8 1.4 1.6
Apixaban 1.5 1.5
Dabigatran 110 1.5 1.4
Dabigatran 150 1.0 1.0
Hart RG. Ann Intern Med. 2007 Jun
19146(12)857-67. PMID 17577005 Connolly S.
Lancet. 2006 Jun 10367(9526)1903-12. PMID
16765759 Connolly SJ. N Engl J Med. 2009 May
14360(20)2066-78. PMID 19336502 Connolly S.
Hotline session at ESC 8.31.10 Connolly SJ. N
Engl J Med. 2009 Sep 17361(12)1139-51. PMID
19717844
38
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 25 35 80
Routine coag. monitoring No No No
Drug interactions Potent CYP3A4 P-gp inhibitors Potent CYP3A4 P-gp inhibitors Potent P-gp inhibitors
Courtesy of John Eikelboom
39
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

40
Warfarin
http//www.anaesthesiauk.com/images/clotting_casca
de.gif
41
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
42
Warfarin vs. no Treatment or Placebo
Hart RG. Ann Intern Med. 2007 Jun
19146(12)857-67. PMID 17577005
43
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

44
Direct Thrombin Inhibitors
http//www.anaesthesiauk.com/images/clotting_casca
de.gif
45
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
46
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
17361(12)1139-51. PMID 19717844
47
RELY
Connolly SJ. N Engl J Med. 2009 Sep
17361(12)1139-51. PMID 19717844
48
RELY
Connolly SJ. N Engl J Med. 2009 Sep
17361(12)1139-51. PMID 19717844
49
RELY
Connolly SJ. N Engl J Med. 2009 Sep
17361(12)1139-51. PMID 19717844
50
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

51
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
52
Connolly S. Hotline, ESC, 8.31.10
53
Connolly S. Hotline, ESC, 8.31.10
54
Connolly S. Hotline, ESC, 8.31.10
55
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

56
ROCKET
  • Question is rivaroxaban non-inferior to warfarin
    for stroke prevention in AF
  • Design RCT, double blinded
  • Patients AF and CHADS2 gt 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
57
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

58
Optimizing Stroke Prevention in AF with
Established and Currently Available
TherapiesThe Role of Vitamin K Antagonists
What Works? What Doesnt?
New Paradigms in the Science and Medicine of
Heart Disease
  • Alan K. Jacobson, MD
  • Director, Anticoagulation Services
  • Loma Linda VA Medical Center
  • Loma Linda, California

59
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.

60
Blood Flow in Atrial Fibrillation
Disturbed Flow (left atrium) Stroke Risk
61
Warfarin in Prospective AF TrialsIntention-to-tre
at analysis
8 6 4 2 0
Control Warfarin
7.0
Stroke Rate (/year)
4.6
4.3
3.6
3.0
2.3
2.1
1.9
0.4
0.9
AFASAK SPAF BAATAF CAFA SPINAF
825 504 922 490 896 p0.03 p0.01
p0.002 pgt0.2 p0.001
person-years p value
Adapted from Atwood, Albers, Herz 19931827-38
62
Anticoagulant Therapy is Effective
RR 79 83 83 73 79 83
Loma Linda VA Medical Center, 2010
63
Anticoagulation of AFRisk Benefit
X
vs.
OR
64
Oral Anticoagulation - Challenges
  • Narrow therapeutic dosing range
  • 10-15 dosing window
  • Variable dosage requirement
  • Effect of medications
  • Effect of diet
  • Effect of liver function
  • Serious consequences if dosing wrong

65
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

66
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.
    ??

67
Systematic Anticoagulation Management
Enabling Technologies POC testing,
computerization
68
Quality Question
  • Are you able to identify, on an ongoing basis,
    which patients are overdue for testing?

69
Active vs. Passive Management
70
Patients Assigned to Warfarin in AF
TrialsIntensity of Anticoagulation When Stroke
Occurred
1.8
4.0
1.7
1.6
3.0
PT
INR
1.5
Ratio
Ratio
1.4
(ISI 2.4)
2.0
1.3
1.2
1.1
1.0
1.0
AFASAK
SPAF I
BAATAF
SPINAF
CAFA
ACCP recommendations INR 2.03.0
Target range for individual study
Connolly et al. J Am Coll Cardiol
19911834955 Ezekowitz et al. N Engl J Med
1992327140612 Hirsh, Dalen, Deykin, Poller.
CHEST 1992312S326S
Petersen et al. Lancet 198917175 SPAF. Circ
19918452739 BAATAF. N Engl J Med 1990
323150511
71
PERCEIVED INR Therapeutic Range
Bleed Risk
Clot Risk
1 2 3 4 5 6 7
INR Intensity
72
ACTUAL INR therapeutic range
73
Incidence Rates of Ischemic Stroke and
Intracranial Hemorrhage
Adapted from Hylek EM, et al. N Engl J Med.
20033491019-1026.
74
Recommended Range for Warfarin Therapy For
Patients in Atrial Fibrillation
  • Target INR 2.5
  • Range INR 2.03.0

CHEST 1998114579s-589s
75
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76
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77
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 ManagementWhich is
    best???Different solutions for different
    patients in different settings

78
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.

79
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).

80
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).

81
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
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