Roxana Mehran教授  美国Mount Sinai医学院

 　　<International Circulation>: How do we balance safety and efficacy when it comes to antithrombotic treatment?

　　Prof. Mehran：That is an incredibly important question because he balance of ischemia vereus bleeding is what a clinician thinks about they approach a patient. They have to choose therapies that might increase their risk of bleeding but at the same time protect them from ischemic events. Obviously， whenever you give a potent agent and you are going after someone’s thrombotic risk， there is going to be some exposure to bleeding. You never want that bleeding risk to outweigh the benefit of protection from ischemic risk. We normally perform a risk stratification. We ask ourselves， is this patient more at risk for bleeding and what is more important? In some cases， this is simple. An old， small lady may have small blockages will not have an important need for potent antiplatelt agents. Exposing her to an extra risk would not be beneficial choice. However， a young， male patient who shows up with an anterior wall MI， whose risk from reocclusion and re-infarction from thrombosis is quite high， in an important artery， you really want to protect them from an ischemic burden. So， are willing to take the chance of a bleeding complication. The difficult part is that many patients have both risks， that is when clinical judgment becomes much more difficult.

　　《国际循环》：我们应如何平衡抗栓治疗的安全性及疗效？

　　Mehran教授：这是一个非常重要的问题，因为临床医生面对患者时必须要考虑缺血与出血之间的平衡。他们不得不选择一些在预防缺血性事件的同时有可能增加出血风险的治疗。很明显，当你应用强效药物来减少某人的血栓形成风险时，也在增加其出血风险。你绝对不会希望药物的出血风险超过它降低缺血风险所带来的获益。我们通常会进行风险分层。我们问自己“这个患者似乎否存在较高的出血风险？何者更重要？”在某些情况下，这很简单。例如，一个伴有小栓塞的弱小的老年女性，无需应用强效抗血小板药物。让其暴露于额外的出血风险中，对她而言不是一个有益的选择。但是，对一个前壁心肌梗死的年轻男性而言，其重要动脉再次发生血栓栓塞及梗死的风险相当高。因此，这类患者则需要冒着有出血并发症的风险来应用抗血小板药物。难题是很多患者同时面对缺血和出血两种风险，这时候临床抉择将更加困难。

　　<International Circulation>: What research is being done into antithrombotic therapy?

　　Prof. Mehran：Keeping to patient risk， unfortunately， clinical trials place all patients into one bucket， and they do not use risk stratification or personalized medicine to see if it really works. The future of research is going to have to rely on comparative effectiveness in certain risk populations to see which one of the agents are best in whom. That has to be the subject of future research. Unfortunately， presently， the new agents are being tested against the weak agents， rather than testing against each other. The problem is that everyone falls into the same risk-category and that is going to have to change.

　　《国际循环》：正在进行的抗栓治疗研究应该关注哪些问题？

　　Mehran教授：不幸的是，临床试验通常对所有患者的风险一概而论，而不对其进行危险分层或是采用个体化的治疗以观察抗栓治疗是否真的有效。未来的研究亟需在特定风险人群中进行疗效对比以确定哪一种药物对上述人群而言最有效。这是未来研究要解决的问题。不幸的是，目前很多新药试验都是将这些新药与疗效较弱的药而非与其他新药进行对比研究。这样的问题是，研究中的每个人都被划入相同的风险等级中，这是需要改变的。