International Circulation: Although advances in catheter ablation for atrial fibrillation make it a good choice for treatment， there are still some high risk patients who choose only anti-arrhythmic drugs combined with an anticoagulant. What is your advice for the treatment of high risk patients who cannot or will not undergo catheter ablation?
　　《国际循环》：尽管房颤导管消融的进展使其成为一个良好的治疗选择，但仍有一些高危患者仅能选择抗心律失常药物联合抗凝药物治疗。您对不能或者不愿接受导管消融的高危患者的治疗有何建议？
　　Dr. Camm: First of all， I think that I should say that catheter ablation does not actually remove the need for anticoagulant therapy. It might be effective if it completely eliminated the possibility of AF recurrence but it is not that effective. If you look at eight or nine recently published studies that had followed patients from three years to six years following an ablation procedure， even though they may have no arrhythmia for some years， by the time you come to the end of the follow-up period， somewhere between 30% and 70% of patients have redeveloped atrial fibrillation. The timing of that re-emergence of arrhythmias is difficult to calculate and therefore， for the time being， I believe high risk patients， even if apparently successfully ablated， should also remain on anticoagulant therapy. Now you are quite right that many patients do not submit to left atrial ablation techniques and are therefore treated with anti-arrhythmic drugs. Anti-arrhythmic drugs are not able to completely suppress arrhythmia and recurrences will be expected. The patient however may be relatively asymptomatic but from the perspective of protecting them against stroke， we have to consider full-time anticoagulation. Anticoagulation， until recently， had to be achieved with warfarin or Coumadin and we had no realistic alternative but today we have another choice. We could use dabigatran. Dabigatran is a direct thrombin inhibitor. It has been shown in a very large clinical trial to be at least as good as warfarin and probably superior to warfarin when you use it at the higher dose of 150mg twice daily. The lower dose of 110 mg twice daily is non-inferior to warfarin and has comparatively less bleeding. So dabigatran is certainly a useful alternative to warfarin and in several countries where the drug has already been approved and is on the pharmacy shelves， the drug is doing extremely well and is being used in preference to warfarin rather than just as an alternative.
　　Dr. Camm：首先，导管消融并未真正消除对抗凝治疗的需要。如果它完全消除了房颤复发的可能性，那么它可能是有效的，但事实并非如此。近期发表的在消融术后对患者随访3～6年的研究发现，即使患者在很长时间内无心律失常，但随访结束时，30%～70%的患者房颤复发。心律失常复发的时机难以估计，因此，对于高危患者，即使成功地消融，也应继续接受抗凝治疗。很多患者不接受左房消融技术，因此给予抗心律失常药物（AAD）治疗。但AAD不能完全抑制心律失常，复发就不言而喻了。患者可能相对无症状，从预防患者卒中的角度来看，需考虑长期抗凝治疗。一直以来，我们都没有理想的替代华法林或香豆素类的药物，但现在我们有了另一种选择——应用达比加群。达比加群是一种直接凝血酶抑制剂。一项大规模的临床试验——RE-LY试验表明，大剂量达比加群150 mg bid至少与华法林相当，且可能优于华法林；小剂量110 mg bid不劣于华法林，且有相对较少的出血率。因此，达比加群无疑是一种有用的替代华法林的药物，现已在多个国家上市，该药物应用情况非常好，是抗凝治疗的优先选择，而不仅仅是华法林的替代药物。

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