iwfal, of course it has advantages over coumadin, I do not love Pradaxa, let me be clear on that but the absolute bleeding risk does seem to be lower on Pradaxa (if dosed properly, see rest of message before reacting) and many bleeds are not life threatening and can be handled conservatively. Patients like it since less blood work is required and dose adjustment (in the absence of renal dysfunction) is not required. Older patients are precisely those who have the greatest difficulty in adjusting their doses of coumadin properly. Having said that I use only coumadin in patients who will need to be anticoagulated during their procedures because of the need to be able to reverse if there is a problem. Cost is a factor also in favor of coumadin. I agree with Dew that once an agent is available that is reversible this will all probably be moot. My statement about not "seeing" the reduction is thromboembolic events was not meant as in comparison to coumadin, it was meant to state that one does see the bleeding complications in the ER but the much greater advantage in reduction of thromboembolic events is (not) "seen" by their reduction. In other words the risk of bleeding is significantly outweighed by the benefit of stroke reduction. The bleeding risk you cite in the elderly may in part be explained by failure to adequately adjust dose for reduced renal function in this population (now being increasingly recognized as very important.) Also the non coumadin oral anticoagulants have a relatively rapid onset and their use can often avoid the need for bridging heparin which carries its own risks. bp
