Warfarin or aspirin: both or others?

In general, aspirin is indicated to prevent thrombosis in conditions associated with high shear rates (i.e., atherosclerosis) and warfarin is indicated to prevent thrombosis in conditions associated with stasis (i.e., atrial fibrillation). While aspirin and warfarin should generally not be used together, their combined use is beneficial in selected patients (e.g., some patients with mechanical valve prostheses). Aspirin in a dose of 75-150 mg per day is indicated to prevent vascular events in patients with ischaemic heart disease and also in patients at high risk of ischaemic heart disease. All patients with atrial fibrillation should be considered for oral anticoagulant therapy, with the decision for its use based on an assessment of the balance between the risk of thromboembolism and bleeding. The recommended therapeutic INR (international normalised ratio) range in non-valvular atrial fibrillation is 2.0-3.0. Warfarin is contraindicated in pregnancy, particularly during the first trimester; however, it may still need to be used in the second and third trimesters in patients with mechanical valve prostheses.     

Clinical governance--watchword or buzzword?

In the latest reform of the National Health Service great emphasis has been placed on the achievement and maintenance of quality. Mechanisms for ensuring this are being set up under the general title of "clinical governance". What is the meaning of this term? The metaphor behind the phrase is of navigation through stormy seas, but who guides the helmsman? Clinical ethics committees could have a part to play in these changes, provided their role is properly understood. Clinical governance is concerned with management according to an agreed set of aims. The task of ethics committees is Socratic rather than managerial. They should ask fundamental questions about the ethical norms of the services provided and give critical appraisal of the moral character of institutional policies. If these tasks are carried out then governance may become a watchword rather than just another buzzword.     

Valvular heart disease--repair or replacement?

An estimated 3 million patients in India need treatment for valvular heart disease. Rheumatic heart disease continues to be the major aetiologic factor. The mitral valve is best conserved with valvotomy or repair. The aortic valve is difficult to repair and is best replaced by a biological substitute (autograft or homograft). The tricuspid valve can be repaired in all patients. Prosthetic valves offer good long term durability but introduce additional risks to the patients. Experience over the past three decades suggests that conservation of natural valve mechanism is currently the best option.