Conclusions and Practical Implications
NOAC represents one of the most important drug discoveries of the new century. These drugs are the result of a new understanding of the treatment of pathological coagulation because, unlike AVK, they target the critical molecules of the coagulation mechanism and not coagulation as a whole. Their development is a result of both the success as well as the limitations of a half a century of treatment with AVK. As a class, NOAC proved to be superior to warfarin for stroke prevention in AF both as anti-embolic efficacy and safety, mainly in terms of major bleeding and especially intracerebral bleeding. NOACs represent palpable progress in the management of AF patients at risk of stroke and effort should be made to implement this therapy in daily practice. However, it should be emphasised that a ‘class’ is only a necessary simplification in the history of a new drug molecule. The pharmacological profile of molecules is as different as the physiological implication of their specific target. Only a better understanding of both components in relation to the clinical profile of the patient would enable us to pinpoint a specific molecule in a specific dosage for a specific patient. When first introduced in practice, one of the main advantages of NOAC was a simplified therapy with few dosages and no need for coagulation monitoring after the model of ‘one fits all’. Available data do not allow us yet to fully individualise NOAC members and dosages for the vast spectrum of all patients but the expectations are at the horizon. As UK Prime Minister Winston Churchill said: ‘ This is not the end. It is not even the beginning of the end. But it is perhaps the end of the beginning. ’