Table 1 Details of the case vignettes

1

Low Stroke risk, Low risk of falls

History: The patient is a 53 year old male, a teacher who participates in regular physical activity. He has a 5-year history of chronic atrial fibrillation which is asymptomatic. For rate control, he takes metoprolol 25 mg bid. He is not taking any antithrombotic therapy. The rest of his medical history is unremarkable, including no history of diabetes, hypertension, or other cardiovascular risk factors. He is taking no other regular medications.

Physical exam: He appears fit. Blood pressure is 130/65; pulse is 78 and irregularly irregular. Cardiac exam is normal except for the irregular rhythm; and the rest of the physical exam is also normal. All laboratory work including complete blood count, electrolytes, urea, creatinine and TSH are normal. ECG confirms atrial fibrillation at 80 beats per minute, but is otherwise unremarkable. Echocardiogram (performed the next day) also shows atrial fibrillation, but is otherwise unremarkable (normal chamber sizes, normal systolic function, and no valvular abnormalities).

2

High Stroke Risk, Low risk of falls

History: The patient is a 74 year old woman. She lives at home with her husband; she is cognitively intact (as is her husband) and is fully independent and active for her age. Past medical history includes hypertension and an ischemic stroke 4 years ago, with no residual deficits. Current medications include hydrochlorothiazide 25 mg daily and atenolol 50 mg daily. She recalled taking aspirin in the past, but stopped on her own years ago. She prefers to walk with a cane, but has never fallen.

Physical exam: The patient looks well for her age. Blood pressure is 138/75, pulse is 83 but irregularly irregular. Cardiac exam is normal except for the irregular rhythm. Neurological exam is normal,

including cranial nerves, visual fields and visual acuity. The rest of the physical exam is also normal. All laboratory work including complete blood count, electrolytes, urea, creatinine and TSH are normal. ECG confirms atrial fibrillation at 80 beats per minute, but is otherwise unremarkable. Echocardiogram (performed the next day) also shows atrial fibrillation, but is otherwise unremarkable (normal chamber sizes, normal systolic function, and no valvular abnormalities).

3

High Stroke risk, high risk of falls

History: The patient is a 72 year old woman who lives with her husband in her own home. She is cognitively intact, as is her husband. Past history includes hypertension, and a previous ischemic stroke 3 years ago, which left her with a mild facial droop but no other neurologic deficits. She also has Parkinson’s Disease which is well controlled but has resulted in her falling 3 times in the last year. She walks with a walker. Her current medications include hydrochlorothiazide 25 mg daily, atenolol 50 mg daily, Sinemet 100/25 mg tablets three times a day. She recalled taking aspirin in the past, but stopped on her own years ago.

Physical Exam: The patient has a mildly shuffling gait, but appears well for her age. Blood pressure is 139/73, pulse is 85 but irregularly irregular. Cardiac exam is normal except for the irregular rhythm. Neurological examination reveals mild left-sided lower facial weakness consistent with her past stroke and cogwheel rigidity of the extremities in keeping with her Parkinson’s. The rest of the physical exam is normal. All laboratory work including complete blood count, electrolytes, urea, creatinine and TSH are normal. ECG confirms atrial fibrillation at 86 beats per minute, but is otherwise unremarkable. Echocardiogram (performed the next day) also shows atrial fibrillation, but is otherwise unremarkable (normal chamber sizes, normal systolic function, and no valvular abnormalities).