The Case against Anticoagulant Therapy.

I WANT to emphasize that I am not against the use of anticoagulants, fundamentally. My "against" implies opposition to an uncritical use of these drugs. The main purpose of my lecture is to show that we do not yet know enough about the value of anti-coagulant therapy. To begin with, I want to talk about the treatment of myocardial infarctions in the acute stage. Nearly everybody will agree today that a favorable effect on the coronary arterial thrombosis is most unlikely. What we can gain is a certain reduction of the secondary thromboembolic complications, nrst of all of the pulmonary emboli. Consequently , the treatment is similar to the use of anticoagulants in many other circumstances , such as postoperative cases, patients with fractures, etc. In this relation I want to show you the frequency of thromboembolic complications in acute myocardial infarctions from various epochs. In series of untreated cases you will see that this frequency is steadily decreasing from 1948 until now (table 1). Today the frequency is around 10 to 15 per cent, which is not much more than that observed in the treated groups. It seems likely to me that the reason for this decrease in spontaneous thromboembo-lism is the increasing mobilization of patients with acute myocardial infarction. There has been a gradual change in the regime used in these patients. How do these results compare with those obtained by anticoagulant therapy? Very well, I think. In the years 1948 to 1954 several well-controlled studies showed a reduction in thromboembolism and mortality.' In 1961, we in Copenhagen published a study consisting of 800 cases of acute myocardial infarc-tion. We found no significant decrease in clinically diagnosed thromboembolic complications nor in mortality.2 What was found in the forties was not observed in the fifties, and how it is now in the sixties nobody knows. Since 1961 I have abandoned the use of anticoagulants in acute myocardial infarc-tion, and for those 22 years our frequency of thromboembolism is 10 per cent. My conclusion is as follows: by mobilization of our patients we can establish prophy-laxis against thrombosis as good or nearly as good as by use of anticoagulants. This is obtained without the risk of bleeding. Some of you may object that the risk of bleeding is small in well-conducted therapy. That is true, of course, but how are conditions generally? One cannot deny that worldwide use of anticoagulants …