Lastly, because I'm a medical director of a warfarin clinic, I am often asked whether there will be a continuing role for warfarin? 

I would say emphatically yes, of course there will be.  For example, no one wants to try these NOACs in a mechanical heart valve patient, so these highest risk patients will still be managed with warfarin. NOACs are contraindicated for mechanical heart valves. Clearly cost may be an issue for some patients – we need to work to improve access to proven anticoagulant therapies. 

We do not really know what the role of the NOACs will be in pregnancy.  Then there are the issues of severe renal impairment and some drug interactions.  Finally, there are still some patients and physicians who cannot get used to the concept of a wider therapeutic index and the lack of any monitoring.  Then, of course, there are always the issues of reversal and adherence.  With that I'll close. Thank you for your attention.