Henry Bounameaux 瑞士日内瓦大学医院 血管和止血科 主任

国际循环：在使用磺达肝癸钠治疗肺栓塞方面，您能否给我们一些建议？Professor Henry：我们机构中，磺达肝癸钠是深静脉血栓和肺栓塞的一线治疗。这种治疗会在最初几天应用，实际上至少5天。在此期间，我们转换为维生素K拮抗剂。磺达肝癸钠是初始治疗。这种选择是经过讨论并确立下来的，因为磺达肝癸钠作为治疗，至少与低分子肝素或普通肝素一样有效，并具有一定优势。这些优势中，最值得一提的是不出现肝素诱导的血小板减少症。至少报道中，极其罕见使用磺达肝癸钠出现血小板减少症。因此，可以认为这种治疗比普通肝素或低分子肝素的常规治疗更加安全。当然，低分子肝素在此方面也同样优异。

Internet Circulation:  Pulmonary embolism and cardiovascular disease are commonly classified as two different disorders.  Please talk about the relationship between the pulmonary embolism and cardiovascular disease.

国际循环：肺栓塞和心血管病通常归类为两种不同的疾病。请谈谈您对肺栓塞和心血管病之间联系的看法。

Professor Henry:  In fact the risk factors for cardiovascular disease are different from the risk factors for pulmonary embolism.  Since diabetes， hypertension， cigarette smoking， and hyperlipidemia are the most important cardiovascular risk factors.  While the risk factors for venous thromboembolism are different， with cancer probably being the first， immobilization， acute disease， and traumophelia are the most important risk factors for venous thromboembolization.  Nonetheless， patients who have cardiovascular disease are more prone to develop venous thrombosis or primary embolism.  That is a fact that has been shown by several other and probably one of the common factors for the two diseases is inflammation.

Professor Henry：实际上心血管病的危险因素与肺栓塞的危险因素不同。糖尿病、高血压、吸烟和高脂血症均是心血管病重要的危险因素。而静脉血栓栓塞的危险因素则不同，肿瘤可能是首位因素，不活动、急性疾病和创伤后组织损伤是静脉血栓栓塞最重要的危险因素。然而，心血管病患者更容易出现静脉血栓或者肺栓塞。这是因为两种疾病存在几种其他的相同危险因素，炎症可能为其中之一。

Internet Circulation:  Some reports in ISTH congress show that increasing BMI is a significant risk factor for the development of PE in women.  What about your opinion?  And please talk about the possible mechanism.

国际循环：ISTH会议上，许多报告显示体重指数增加是女性肺栓塞的一个重要危险因素。对此您如何看待？请谈谈可能的机制？

Professor Henry:  Obesity， or an increased BMI， has been shown to be an important risk factor for venous thromboembolism.  This may be due to reduced mobility of patents who are obese， and also as I mention earlier， these patients may probably have a chronic， low-grade， permanent activation of the inflammation system so they are at higher risk.  These patients are also prone to have co-morbidities that can increase the occurrence of hospitalization， again compounding the risk factor of immobilization.  A kind of vicious circle if you will， resulting in these patients having an increased thromboemolitic risk.

Professor Henry：肥胖或者体重指数增加，已证实是静脉血栓栓塞的一种重要危险因素。这可能因为患者由于肥胖减少了活动，并且如上所言，这些患者可能存在一种慢性、低度、持久性的炎症系统激活，使其处于更高的风险中。此外，这些患者容易合并其他疾病，引起住院几率增加，再次增加了不活动的风险。如果您同意，这就是一种恶性循环，使得患者发生血栓栓塞的风险增加。

Internet Circulation:  In this congress， some people suggest that the administration of empiric systemic anticoagulation (ESA) before confirmatory radiographic testing in patients with suspected pulmonary embolism， what about your opinion?

国际循环：此次会议中，许多人建议对怀疑肺栓塞的患者，应在放射检查确诊之前进行经验性全身抗凝治疗，对此您有何观点？

Professor Henry:  Of course it may depend on how long it takes to have the diagnostic workup performed.  This is very different in different institutions.  If you can have the diagnostic tests done very quickly it may not be necessary， but often the diagnostic workup takes several hours or sometimes one or two days.  In that case， in patients with suspected pulmonary embolism， we are introducing empirical anticoagulant treatment if the clinical suspicion is at least moderate or high.  If it is a low clinical probability that a patient is presenting with venous thromboembolism then we do not introduce such anticoagulant treatment during the diagnostic workup because we feel that the risk of hemorrhage due to treatment is higher than the risk of experiencing a recurrence during these few hours.  That is the attitude we are currently using in my institution.

Professor Henry：当然这取决于完成诊断措施所需要的时间。不同机构之间，差异很大。如果能在很短时间内完成诊断性检查，这种治疗可能没有必要。但是诊断措施常常需要数小时，有时甚至需要1~2天；此时，怀疑肺栓塞的患者如果临床怀疑至少为中到高度，我们会建议进行经验性抗凝治疗。如果患者出现静脉血栓栓塞的临床可能性很小，我们将不会在诊断期间进行这样的抗凝治疗，因为我们认为在此期间，治疗引起出血的风险将高过复发的风险。这是目前我所在单位所采取的方法。

Internet circulation:  Yes， I know in China the attitude towards such cases is similar， proactive treatment for high/moderate risk patients appears indicated while for low risk patients are “wait and see” attitude is applied.  Would you please share your experience on anticoagulation with the chronic pulmonary hypertension in patients with previous pulmonary embolism?

国际循环：对。我知道中国也采取相似的方法，对高危/中危患者积极进行治疗，对低危患者进行“留观”。对先前有过肺栓塞的慢性肺动脉高压患者抗凝治疗方面，能否分享一下您的经验？

Professor Henry:  These patients should probably be anticoagulated on a long-term basis.  There is no good evidence for this because， to my knowledge， there are no long-term clinical studies comparing patients who have been anticoagulated with those that have not been anticoagulated， who also had chronic pulmonary hypertension.  But opinion is that these patients already have pulmonary hypertension and if they are not protected against even small recurrences， they may a recurrent event if they are not anticoagulated.  These recurrent events， even if they are small， can have big consequences because of the prior state of these patients.  My suggestion is to give long-term anticoagulant treatment in patients with post-embolic， chronic pulmonary hypertension.

Professor Henry：这些患者可能需要进行长期抗凝治疗。据我所知，对此尚未有很好证据，没有对比慢性肺动脉高压患者抗凝治疗和不抗凝治疗的长期临床研究。但有观点认为这些患者已经有了肺动脉高压，如果不能预防甚至很小的复发，如果不进行抗凝，他们会再次出现复发事件。由于患者先前的状态，这些复发事件即使很小，也可能导致严重的后果。我建议应对栓塞后、慢性肺动脉高压的患者进行长期抗凝治疗。

Internet Circulation:  Would you please give us some advice on the treatment of pulmonary embolism with fondaparinux.

国际循环：在使用磺达肝癸钠治疗肺栓塞方面，您能否给我们一些建议？

Professor Henry:  In my institution， the first line of treatment of deep vein thrombosis and pulmonary embolism is fundaparinux.  This is the treatment we give for the first few days， at least five days actually.  During that period we switch to a vitamin K antagonists.  The initial treatment is fundaparinux.  This choice was debated and decided because fundaparinux is at leas