<International Circulation>:  With regard to treatment， the first problem as you said is to see past the masking of their symptoms. We may be able to pick out who is more at risk when they are younger， but not so much when they are elderly. If we do see past this and decide we have to treat this person， what do we need to take into consideration when deciding between medical treatment and PCI for instance?

　　《国际循环》：在治疗方面，像您刚才谈到的第一个问题是查看患者既往病情以了解是否有掩盖症状的情况。当患者年轻时我们可能很容易区别出哪些是高危患者，但是老年患者就不那么容易被区分。如果我们了解了患者既往病史并决定对其进行治疗，那么我们在选择药物治疗还是PCI治疗的时候需要考虑哪些方面的问题？

　　Dr Wenger: Again， it is probably more medical treatment versus bypass surgery than PCI because PCI is not associated with as much of an increase in complications with older age compared with younger as bypass surgery is. Possibly the off-pump surgery may do better in elderly patients if their anatomy is suitable for off-pump bypass. We have to look at cognitive function. Are the patients capable of making decisions， capable of understanding the magnitude of differences in their choices? How frail are they? Are they barely functioning so that we are not sure we are going to give them that much more functional capacity? There are a whole variety of extent-of-cognitive dysfunctions through to true dementia that sometimes are unmasked by illness or maybe not even recognized until illness occurs. The estimate of frailty and the whole issue of cognition are very important. One of the things that we discussed here at the meeting was that the time to have some of these conversations with patients is during a stable phase of the illness; when they have， for example， chronic stable angina. That is reasonably well controlled with medical therapy. There should be some conversation as to what they want to happen if there is suddenly a major deterioration of symptoms. Do they want just symptomatic therapy? Do they want us to try to increase their medical therapy? Or if we think there may be some benefit from something as invasive as a percutaneous intervention or even more invasive as bypass surgery， how do they feel about that? It needs to be a presentation when they are stable of the relevant risks and benefits. Sometimes this is better done in advance. Common in the US， but probably less common elsewhere， are comments about end-of-life decisions. It is not unusual for US patients to have a living will where they will decide what they want or don’t want or what they want their family to decide or not to decide if they are incapable of making the decision. There are some older patients who will say， medical treatment no problem. Many do not want to be placed on artificial ventilation. Many do not want very aggressive life saving therapies. But that has to be discussed periodically because at times you will see a patient who says to you that they have a daughter or granddaughter who will be married in the next six months and that I should do anything so they can see their granddaughter get married. There are life events that make people change their minds but this is the luxury of a primary care physician or a long-term treating cardiologist who knows the patient and knows what they want. Other patients will say they just want to be comfortable; they don’t want anything unusual done but they don’t want to have pain and they don’t want to have anything aggressive done. Then you need to really respect the decisions that they make.

　　Wenger博士: 我重申，对老年患者可能药物治疗和旁路移植比PCI更多，因为与年轻患者相比，老年患者接受PCI后并发症的发生率更高，而接受旁路移植手术的年轻患者和老年患者其并发症发生率相似。可能如果老年患者的解剖情况适合进行非体外循环旁路手术时，进行非体外循环手术的效果会更好。我们需要看患者的认知功能。是否患者能做出决定，是否能明白他们将要做出的选择之间有多大的差异。患者是否很虚弱？是否他们只能勉强维持生存因此我们不确定是否会给他们更多的功能性行为能力？有很多种不同程度的认知功能障碍，甚至是有些时候因疾病而暴露的或可能直到发病才被确认的真正的老年痴呆。对患者身体状况和整个认知状态的评估非常重要。我们在此次大会上谈到的问题之一是与患者进行这些谈话的时候患者正处于疾病的稳定期，比如当患者为慢性稳定性心绞痛时。因此用药物治疗就能很好的合理控制病情。如果出现突然的病情加重，应该进行谈话了解他们想得到什么样的治疗。他们只是希望对症治疗吗？他们是否希望我们尝试增加他们的药物治疗吗？或者如果我们认为进行侵入性操作如经皮介入治疗或更侵入性的操作如冠状动脉旁路移植术能使患者获益更多，他们的感想又是什么？这是当患者处于相关风险和获益稳定期时应该拿出来讨论的问题。有些时候这些问题应该提前解决。比如在美国关于生命结束的讨论很普遍，但是可能在其他的地方并非如此。美国患者普遍都有生前遗嘱，他们将会在生前遗嘱中自己决定想要什么不想要什么，或当他们不能自己做决定时他们是否想要自己的家人来做决定。有些老年患者会认为只要药物治疗就行了。很多患者不希望接受人工通气。很多人不想要非常有侵入性的挽救生命治疗方法。但是这些问题要定期讨论，因为有时候你会遇到一个患者对你说他们有女儿或者孙女将要在接下来的6个月内结婚，他们希望你能做一些治疗使他们能看到自己的孙女结婚。生活事件会改变人们的想法但是这是初级保健医生或长期心脏病治疗医师的奢望，这些医生了解患者并知道患者想要什么。另外的一些患者会说他们只是希望过得舒适一点，他们不想要非常规的治疗但是他们也不想经历疼痛，同时他们还不想进行侵入性的治疗。这时你需要真正尊重患者所做的决定。