Samuel Z Goldhaber  美国布莱根妇女医院 静脉血栓研究组 主任
 

Internet Circulation: High D-dimer levels in patients with pulmonary embolism (PE) have been shown to be associated with adverse events including mortality. The mechanisms involved remain unclear. It has been suggested that degradation of a more extensive PE is perhaps able to induce greater D-dimer release， what is your opinion about this as well as about the association between D-dimer and short-term clinical outcome in patients with PE?

国际循环：已证实肺栓塞患者出现高水平的D-二聚体与死亡等不良事件有关。与之相关的机制尚不清楚。有研究表明大面积肺栓塞降解时可能诱发更多的D-二聚体释放，对此您如何看待？此外，您如何看待D-二聚体与肺栓塞患者短期临床转归之间的关系？

Professor Goldhaber:  A higher D-dimer level usually means a larger pulmonary embolism.  However for prognosis， the best prognostic features are right ventricular size and right ventricular function.  Not the D-dimer level.  Regarding the association between D-dimer level and short-term clinical outcomes， there is not a very good association.  A better association is right ventricular enlargement usually means worse short-term clinical outcome. 

Professor Goldhaber: D-二聚体水平越高，通常表示肺栓塞面积更大。然而对预后而言，最好的预测指标是右室大小和右室功能，而非D-二聚体水平。至于D-二聚体水平与短期临床转归之间，并不存在良好的关联。更好的关联是右室扩大，其通常预示短期的临床转归更差。

Internet Circulation:  So you know traditional anticoagulation agent such as heparin and warfarin have the specific antagonist， but to new anticoagulation agent， there is no good way to reverse the role of its antagonism， so would you please share your experience with us on how to reduce the bleeding complication in patients undergoing anticoagulation therapy?

国际循环：您知道传统的抗凝药物如肝素和华法林都有特异性拮抗剂，但对于新型抗凝药物，并没有很好的手段对抗其抗凝作用。对此，能否与我们分享您的经验——如何处理那些正接受抗凝治疗患者出血并发症？

Professor Goldhaber: With the old anticoagulate agents like heparin， we reverse bleeding complications with protamine， and for warfarin we reverse bleeding with fresh frozen plasma (FFP) or with vitamin K.  The new anticoagulants， we don’t have any specific reversal agent.  This might be a special challenge for us.

Professor Goldhaber:老的抗凝药物如肝素，我们可使用鱼精蛋白对抗出血并发症。对于华法林，我们可使用新鲜冰冻血浆或维生素K进行对抗。但是，对新的抗凝药物，我们并没有任何特异性的对抗药物。对我们而言，这可能是一个特别的挑战。

Internet Circulation: You haven’t dealt with bleeding complications in patients receiving the new agents?

国际循环：对正在接受新抗凝药物治疗的患者，您有没有处理过出血并发症？

Professor Goldhaber:  The bleeding complication rates for the new anticoagulation agents are supposed to be about the same as with the old， but we don’t have specific reversal agents.  For example fondaparinux， we don’t have a specific reversal agent.

Professor Goldhaber:新型抗凝药物出血并发症的发生率可能与老药相似，但是我们并没有特异性的对抗药物，例如磺达肝癸钠，我们就没有一种特异性拮抗剂。

Internet Circulation:To devise an appropriate treatment strategy， accurate and rapid risk stratification and prognostication are required; Please talk about the risk stratification of pulmonary embolism?

国际循环：为建立一个合理的治疗策略，需要有准确、快速的危险分层和预测。请谈谈您对肺栓塞危险分层的看法？

Professor Goldhaber:  For risk stratification we look for high risk features.  High risk means low blood pressure; high， very rapid heart rate; englarged right ventricle either on the echocardiogram or enlarged right ventricle on chest CT scan， or an elevation in the troponin level.

Professor Goldhaber:对于危险分层，我们要找出高危因素。高危因素包括低血压、很高/很快的心率、超声心动或胸部CT检查提示右室扩大、或者肌钙蛋白水平升高。

Internet Circulation: In your clinical practice， can you comment about the use of risk stratification to guide clinical practice?  Also， the score system for pulmonary embolism?

国际循环：根据您的临床实践，能否评论一下如何使用危险分层指导临床实践？此外，肺栓塞积分系统怎么样？

Professor Goldhaber: Yes， we think risk stratification is very important in guiding clinical practice.  The score system， or pulmonary embolism severity index， is very popular in Europe although not so popular in the United States.

Professor Goldhaber:是的，我们认为危险分层对于指导临床实践非常重要。积分系统或者肺栓塞严重指数在欧洲非常流行，然而在美国并不常用。

Internet Circulation: would you please give us some advice on the selection of anticoagulants or the strategy of treatment for those low-risk patients with pulmonary embolism?

国际循环：对那些低危肺栓塞患者，在选择抗凝药物或治疗策略方面，能否给我们一些建议？

Professor Goldhaber: Sure， so for low risk patients we use either a low molecular weight heparin as a bridge to warfarin， or we use fondaparinux as a bridge to warfarin. Fondaparinux is an anti-10A agent， its injectable， and basically serves as an ultra-low molecular weight heparin with the five sugar molecules， a pentasaccharide， that serve as the active anticoagulation portion of the heparin molecule.

Professor Goldhaber:当然可以。对于低危的患者，我们可选用低分子肝素作为华法林之前的治疗，也可选用磺达肝癸钠作为华法林之前的治疗。磺达肝癸钠是一种抗Xa因子药物，能够注射，基本上可看作一种由5糖分子组成的超低分子肝素，由戊多糖作为肝素分子的活性抗凝部分。

Internet Circulation:  As you know fondaparinux is expensive for Chinese people， I would like to know the therapy costs.

国际循环：您知道磺达肝癸钠对中国人而言非常昂贵，我想了解一下其治疗的费用。

Professor Goldhaber:  Yes， fondaparinux is expensive for everyone.  I don’t know the specific therapy costs but I can surely say it is not inexpensive.  That is the choice， either low molecular weight heparin or fondaparinux， as a bridge to warfarin.

Professor Goldhaber:对，磺达肝癸钠对于所有人都很贵。我也不知道磺达肝癸钠特定的治疗费用，但我确认其很不便宜。可以选用低分子肝素或者磺达肝癸钠，作为华法林之前的治疗。

Internet Circulation: We know you are an important lecturer at the ISTH congress. Is there anything that has been presented that you are particularly excited about? And what do you think about the future directions of anticoagulation drugs?

国际循环：我们知道您在ISTH会议上有一个很重要的发言。是否存在一些让您特别激动的事情？您认为抗凝药物的未来方向是什么？

Professor Goldhaber:  Yes， I am excited that more attention is being focused on pulmonary embolism and， particularly， that more awareness is being made for pulmonary embolism.  We are starting to educate the public just like we educated the public about heart attacks.  In the future I think we will have oral agents that provide anticoagulation without drug dose adjustments.  I predict in the future we have oral anticoagulation drugs given in fixed dose without the need for laboratory monitoring.

Professor Goldhaber:是的。大<