《国际循环》：非常感谢您接受本次采访。我的第一个问题是，房颤治疗的基本原则众所周知，但处理合并症时这个问题就变得更加复杂。那么，我们如何处理有心衰，CHADS2评分高并且出血风险高的患者？

　　Prof. Packer: Heart failure is problematic for a couple of reasons. One reason is because drugs work differently. The metabolism of drugs is different. There are higher risks in using antiarrhythmic drugs so we have narrowed down the list to basically two drugs; dofetilide and amiodarone as being effectively safe for patients with heart failure. So that narrows the list as far as drugs goes. As far as ablation goes， it is also problematic from the standpoint of long-term outcomes. If the patient has a non-ischemic cardiomyopathy in the low ejection fraction and the fribillation is contributing to that then you can expect they will show benefit. That’s the tachycardia/ fibrillation patients. You would expect that they would show benefit. Fifteen percent increase in ejection fraction is one example， other changes in six minute walk and other， usual measures of heart failure. The risk might be different though in that the chance of fluid overload， proliferation， a stroke might be higher because they are predisposed. Still the results look good. It’s not quite as clear in patients who have ischemic cardiomythapies. You asked about CHADS2 score. If we are looking at patients with hypertension， diabetesis， prior stroke or TIA， or underlying left atrium obstruction， female gender， age… If you are looking at CHADS2 scoring， it’s age 75. If you are looking at CHADS2 best scoring then it is age 65. Those patients are all at a higher risk. But from the standpoint of ablation， as long as there is no pre-existing clot we go in with a blade and do a TEE to be certain about that. Antiarrhythmic drugs in those groups are similar in use to those for those who have underlying ventricular dysfunction. The bigger question is how do you anticoagulate when there are those kinds of coronal morbidities. If the bleeding diathesis that they have is substantial， then you may be stuck in a situation where you can’t anticoagulate. I must say though that I think this type of situation is quite rare. Patients may have a problem with for example， warfarin. If a source can be found than that source can be treated primarily， and perhaps eliminated. Maybe a problem with a drug with for example， Ambigram where there may be more GI side effects. But if you look at the new oral agents it takes a fairly substantial bleeding risk to absolutely counter- indicate using one of those drugs. I think the point has to be that you need to understand the underlying problem and treat it and then you can’t overdo the anticoagulates. Watch the INR， keep it down between 2 and 2.5. I think those are some of the issues we deal with when we are significant comorbidities.

　　Packer教授：心衰确实是个问题，有以下几个原因。一是药物作用不同。使用抗心律失常药危险更高，因此，我们将用药总体上限制为两种：多非利特和胺碘酮，这两种药物对于治疗心衰患者安全有效。关于消融，从远期结果来看，也存在问题。如果患者有非缺血性心肌病，射血分数低，且房颤持续，那么可以期待这些心动过速和房颤患者会从消融治疗中获益。消融术后射血分数可增加15%，6分钟步行距离等心衰相关指标也有所改善。尽管心衰患者存在体液潴留，卒中风险可能更高，射频消融效果仍很好。对于缺血性心脏病患者，则不那么明确。你问到CHADS2评分问题，CHADS2评分包括高血压、糖尿病、既往卒中或TIA或潜在左心功能不全，关于年龄，CHADS2评分为≥75岁，而CHADS2-VASC评分为65岁以上。伴随这些因素的患者风险均较高。但从消融角度来说，只要通过经食管超声确定没有血栓，就可以治疗。对于这些患者，抗心律失常药的使用和有潜在心室功能不全的人，更大的问题是存在这些合并症时应当如何抗凝治疗。如果患者存在严重出血倾向，那么可能就处于无法抗凝治疗困境。尽管我认为这种现象很少见。患者还有可能有华法林问题。使用抗凝治疗时有可能增加胃肠道出血。但新型口服抗凝药大大降低消化道出血绝对风险。我认为应当理解潜在问题并进行治疗，不能过度使用抗凝药。监测INR，使其保持在2~2.5。这些是我们面对合并症时应当注意的。

　　<International Circulation>: So basically it’s the risk of stroke and morbidities with the anticoagulants rather than the antiarrhythmic drugs and the ablation technique.

　　《国际循环》：那么，这部分患者主要风险来自卒中和抗凝药不良反应，而非抗心律失常药和消融术。

　　Prof. Packer: Let me just say one more thing concerning that then. We worry a lot about patients who have more comorbidities and if you look at CHADS2 test， patients who have multiple morbidities. It’s important that they be treated. People think maybe they have atrial fibrillation it’s incredibly important that someone goes through the effort to ensure that they are anticoagulated. An enormous number of patients that should be anticoagulated aren’t. That maybe is a problem of the primary care givers. If you look at trials like ROCKET it is amazing how little time patients spent in therapeutic range. So it is an unnecessary increase in drugs which can be avoided by understanding drug therapies we already have.

　　Packer教授：关于这个问题，我还要多说一句，我们关注CHADS2评分时，会对有多重合并症的患者产生担忧。他们接受治疗是很重要的。很多人可能认为对于房颤患者来说，保证他们接受抗凝治疗非常重要。大量应当接受抗凝治疗的患者实际上并未接受。这可能是社区医生问题。如果看ROCKETS这些试验，会发现患者凝血指标处于治疗目标范围的时间非常少。因此，通过理解已有药物治疗方法，可避免不必要增加药物。