1. <International Circulation>: One indication of fondaparinux is for the prophylaxis of deep vein thrombosis which may lead to pulmonary embolism. We all know that DVT is a major complication in some patients with big surgery such as abdominal surgery， hip replacement， or knee replacement surgery and more. In China， Seldom to prescribe anticoagulant agents to these patients is often due to physicians’ perceiving the risk of major bleeding in association with anticoagulant therapy as unacceptably high. What is the status of anticoagulant for the prophylaxis of DVI in USA at present? Would you like to share us your experience of fondaparinux or other anticoagulants for the prophylaxis of deep vein thrombosis?
《国际循环》：磺达肝癸钠的一个适应证是预防深静脉血栓，后者可导致肺栓塞。我们知道深静脉血栓也是许多大手术患者的一个主要并发症，如腹部手术、髋关节或膝关节置换。在中国，医生们由于担心抗凝治疗引起大出血的风险将会很高，而很少对上述患者应用抗凝药。美国应用抗凝药预防深静脉血栓的情况如何？能否与我们一同分享您在使用磺达肝癸钠等抗凝药预防深静脉血栓方面的经验？
Prof.Samuel Z. Goldhaber: In the US， DVT and pulmonary embolism are the third major cause of cardiovascular death and disability. Myocardial infarciton is no. 1 and stroke is no. 2. Deep vein thrombosis and pulmonary embolism is no. 3. It’s very difficult to make the diagnosis of DVT and to make diagnosis of pulmonary embolism. So it’s much easier to prevent DVT and to prevent pulmonary embolism rather than to try to diagnose it and then treat it. So for us， prevention is very important. And we do routine prophylaxis with anti-coagulants for patients who are in the hospital at high medical risk， patiens with cancer， pnermonia， immobility， stroke and patients of high surgical risk who are undergoing major surgery or who suffer from major trauma. All these patients we give small daily doses of injected anti-coagulant to prevent DVT and to prevent pulmonary embolism.
Samuel Z. Goldhaber教授：在美国，深静脉血栓形成（DVT）和肺栓塞是心血管死亡和残疾的第三大原因。心肌梗死和卒中分列第一位和第二位。DVT和肺栓塞均难以诊断。因此，与试图确诊和治疗这两个疾病相比，预防更容易些。预防对我们来说非常重要。对院内高危患者常规地给予抗凝剂的预防性治疗，例如癌症、肺炎、卧床、卒中、接受大手术或有重大创伤的外科高危患者。所有患者每日均注射小剂量抗凝剂以预防DVT和肺栓塞的发生。
2. <International Circulation>: OASIS-5 shows that similar efficacy of fondaparinux and enoxaparin in reducing cardiac events， but a significant reduction in bleeding with fondaparinux in non-ST-elevation ACS patients， this net benefit is seen both in the medical approach and in the interventional approach. This net benefit is being seen both in the medical approach and in the interventional approach. OASIS 6 trials shows that primary end and severe bleeds did not differ significantly between the two groups in patients STEACS undergoing primary PCI， but there was a higher rate of guiding catheter thrombosis and more coronary complications with fondaparinux. Why did these trials have different results for patients undergoing PCI? Is it safe for patients who underwent PCI to receive fondaparinux therapy? How to avoid these complications if we have used fondaparinux before PCI?
《国际循环》：OASIS-5显示磺达肝癸钠和依诺肝素在减少非ST抬高急性冠脉综合征患者心脏事件的作用相似，但前者的出血显著减少，这种净效益在药物组及介入组均能见到。但是OASIS-6表明直接PCI的ST抬高型急性冠脉综合征患者，磺达肝癸钠组的导管血栓和其他冠脉并发症更多见。为什么应用磺达肝癸钠的介入患者会存在上述不同结果？PCI患者应用磺达肝癸钠是否安全？如果PCI前已应用了磺达肝癸钠，应该如何避免上述并发症？
Prof.Samuel Z. Goldhaber: For patients undergoing PCI， they might require supplemental heparin on top of the fondaparinux. But for patients with hip fracture， total hip replacement or total knee replacement， there is FDA approval to give fondaparinux 2.5mg once daily. To avoid the complication， you have to make sure that the fondaparinux is given just before the PCI or to supplement the fondaparinux with additional intravenous heparin. If you have long time elapses between the fondaparinux and the PCI， then it is important to give the intravenous heparin.
《国际循环》：接受PCI的患者可能需要在磺达肝癸钠的基础上辅以肝素治疗。但是，对于髋部骨折的患者、接受全髋置换术或全膝关节置换术的患者，FDA批准每日给予2.5mg的磺达肝癸钠。为了避免PCI合并症的出现，需要在PCI之前给予磺达肝癸钠，或者是磺达肝癸钠辅以静脉肝素治疗。如果给予磺达肝癸钠和PCI之间的间隔过长，给予静脉肝素是很重要的。
3. <International Circulation>: From pharmacology， we can learn that fondaparinux does not activated factor II and affect platelet function or fibrinolytic activity at the recommended dose， so fondaparinux is relatively safe and does not require routine monitoring. But in clinical practice， many patients take aspirin， clopidogrel or warfarin together to prevent blood clots. How to use fondaparinux in those patients? How to reduce the risk of bleeding?
《国际循环》：从药理学可知，推荐剂量的磺达肝癸钠不激活凝血因子II、不影响血小板功能、纤溶活性，所以相对安全，使用时不用常规监测。但是临床中许多患者需要同时服用阿司匹林、氯吡格雷、华法林等抗凝药物预防血栓形成。这些患者应该如何使用磺达肝癸钠？怎样才能减少出血的风险？
Prof.Samuel Z. Goldhaber: So patients will generally require small doses of aspirin in addition to fondaparinux. The two work together. so I think for ACS these two agents will be recommended together to be used before PCI.
Samuel Z. Goldhaber教授：通常除了磺达肝癸钠以外，患者还需要小剂量的阿司匹林。两者协同发挥作用。因此，我认为对于ACS来讲，会一起推荐磺达肝癸钠和阿司匹林，在PCI之前应用。
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