Anticoagulation: the old and new

A 54-year-old man from South America presents to you as a new patient. He has a history of a mitral valve replacement with a St Jude mechanical prosthesis 10 years ago for severe rheumatic mitral stenosis and regurgitation.

He has been well since. He is on digoxin 250 micrograms daily and warfarin, with latest INR being 2.8.

Physical examination reveals a well man with an irregular pulse, a prosthetic first heart sound and no cardiac failure.

His ECG is above.

The patient has heard from friends about the new drug dabigatran and is keen to start this instead of warfarin. 

He is a wealthy man and asks about a private script, aware of the issues at present in Australia with the PBS listing.

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