<International Circulation>: Great. Thank you very much. Moving on to stroke prevention. Anticoagulant therapy is an effective measure in the prevention of atrial fibrillation (AF) related to thromboembolic complications， but treatment status has been worrying. Within the last two years new oral anticoagulants are increasingly used and there are distinct advantages to them， however， what are the important considerations when deciding when and how to use them?

　　《国际循环》：非常感谢。我们继续讨论卒中预防问题。抗凝治疗是预防房颤相关血栓栓塞并发症的有效方法，但治疗状态令人担忧。最近两年新型抗凝药使用越来越多，这些药物有明显优势。然而，决定什么时候使用，如何使用新型抗凝药，需考虑哪些问题？

　　Prof. Alpert: There is a risk score for stroke. The older score is called CHADS2 and the newer score， or the expanded score is called CHADS-VASc. It predicts what percentage chance the patient has of developing a embolic stroke. If the chance gets above generally 1.5 to 2 percent than we recommend that the patient do anticoagulation. And for years all we had was a medication called warfarin. It has a very narrow therapeutic to toxic ratio so in other words you need to maintain the patient for a very narrow scope of blood test therapy or else they are at a high risk for bleeding or ineffectiveness if they are too low. So it’s a real problem. There are now three new anticoagulants released on the market in the United States; rivaroxzaban， dabigatran and apixaban. They are blockers of the clotting cascade and don’t need the blood test and keep people all pretty much in the right range on similar doses.

　　Alpert教授：卒中有危险评分，较老的叫CHADS2评分，更新的评分，或者说扩展评分叫CHADS2-VASC评分，可以预测患者发生血栓性卒中几率，如果达1.5%~2%，推荐患者接受抗凝治疗。多年来我们有华法林这个药物。华法林的疗效毒性窗很窄，治疗时需使患者保持在非常窄的血液检测范围内，否则就会处于出血高危或无效。这是个实际问题。目前美国市场上有3种新型抗凝药：利伐沙班、达比加群和阿哌沙班。他们都是凝血反应阻断剂，不需血液检查，所有患者服用同样剂量可使凝血功能保持在合适范围。

　　<International Circulation>: So do you see these drugs overtaking warfarin in the next couple years?

　　《国际循环》：这些药物会在未来几年中取代华法林吗？

　　Prof. Alpert: The most important thing in the United States is cost. So it depends on your insurrance. When you have insurance where the patient’s burden of the cost is reasonable you see people switching over because you don’t need regular blood tests， there aren’t the same dietary restrictions as there are with warfarin so it’s much easier to use so many patients are switching over but still 60 to 65 percent are still taking warfarin. It’s inexpensive. If we have patients who have been successfully being managed on warfarin for years and they are comfortable we leave them on warfarin. The new drugs are not good for people with prosthetic heart valves. It’s only for preventing stroke-related atrial fibrillation.

　　Alpert教授：在美国，最重要的问题是开支，取决于你的保险。如果有医疗保险患者负担合理的话，人们就会使用新型抗凝药。新型抗凝药不像华法林有饮食限制，使用简便很多。许多患者在改用新型抗凝药，但还有60%~65%患者仍在服用华法林。华法林价格便宜。如果患者使用华法林多年且效果和耐受性良好，可继续使用华法林。新药对植入人工心脏瓣膜的患者效果没那么好，只能用于预防房颤相关卒中。

　　<International Circulation>: Great. Are there any other topics related to pharmacology being presented at the ACC13 are of interest to you?

　　《国际循环》：很好。ACC13上还有哪些和药理学相关主题让您感兴趣？

　　Prof. Alpert: Yea， there were several. We had six different sessions of different topics. One was the whole question of vitamin D and its properties not as a vitamin but as a hormone. It is essential for brain health， bone health， heart health. It’s a very ， very important component. Recently people have been measuring vitamin D in patients and we have notice that， particularly for patients who are not outdoor very much or where the daylight hours are short， the people have low levels of vitamin D. The skin manufactures vitamin D when in the sunlight. Low levels of vitamin D leads to increased risk of bone fractures and there is a new proposition that low levels of vitamin D may lead to increased risk of heart attack but there’s not really enough scientific data yet to make any conclusions concerning the relationship between vitamin D and the heart. That was the conclusion of this session. The data is pretty strong with respect to soft bones as we know vitamin D and calcium help to reduce the risk of fracture but there’s no real hard data concerning cardiovascular disease. Therefore the feeling of everyone who spoke was that we shouldn’t be giving people doses of vitamin D for heart disease because we don’t know if that makes any difference.

　　Alpert教授：是的，有几个主题。我们有6个不同主题专题会。其中一个是关于维生素D，维生素D作为激素而非维生素的特点。维生素D对于大脑、骨骼及心脏健康非常重要。近期有人对患者的维生素D进行测定发现，尤其是不经常户外活动的患者或日照时数少的地区，人们维生素D水平较低。皮肤只有在日光下才能够合成维生素D。维生素D水平低可导致骨折风险增加。还有人认为维生素D水平低可能增加心肌梗死风险，但目前还没有确切科学数据对维生素D和心脏的关系下任何结论。关于维生素D和钙对软骨的关系，已有强有力证据证实维生素D可降低骨折风险，但仍然没有关于心血管疾病的真正硬数据。因此，每个发言者感觉都是不应当让人们服用维生素D预防心脏病，因为我们并不知道是否有效。

　　<International Circulation>: Would you be recommending vitamin D though to elderly patients anyways because of the associated benefits related to bone health? So could it come as a recommendation to everyone over a certain age?

　《国际循环》：那么，您是否会因为维生素D和骨骼健康相关的获益而推荐所有老年人服用维生素D？是否每个人到了一定年龄都应当推荐？

　　Prof. Alpert: Well some people don’t need it and if you give too much vitamin D and calcium people can get kidney stones. Therefore we recommend a test called a bone-density test. It tests how firm and calcified the bones are. And anyone who gets a score below a certain level should be put on vitamin D and calcium. There are other drugs as well.

　　Alpert教授：有些人并不需要。如果维生素D和钙过量，会导致肾结石。因此我们推荐骨密度检查。这个检查可以显示骨骼的坚固度和钙化情况。每个人都可得到一个分数，低于一定分数应补充维生素D和钙，还有其他药物。

　　<International Circulation>: Great. Thanks. So， any other topics related to pharmacology?

　　《国际循环》：很好，还有其他关于药理学的专题吗？

　　Prof. Alpert: Yes. There was also a very interesting session on adverse stroke reactions where people take one drug and then they take a second drug and there is a bad effect due to the interaction of those two drugs. For example， the body， usually the liver chews up drugs so you don’t build up giant levels in your body. You body has to eliminate them. So it turns out that some drugs interfere with the metabolism of other drugs and you can build up toxic levels of these drugs in your system. So there’s a huge number of such interactions and what is going to end up happening is that a lot of people are putting these lists on the computer so when a doctor prescribes a drug there will be an alert that warns of the interaction between that drug and the ones the patient is already taking and further recommendations. So there’s a lot of talk about that. It’s a very hot topic in the United States. Some drugs cause changes on the elecardiograph that can cause dangerous and even fatal arrhythmias. So you have to be very careful about those kinds of interactions.

　　Alpert教授：是的，还有1个非常有意思的专题关于药物不良反应，人们服用1种药物后再服用第2种药物，两种药物相互作用而产生不良反应。人体主要靠肝脏代谢药物，因为身体会清除药物，所以药物浓度不至于太高。有些药物会影响其他药物代谢，使得这些药物达有毒水平。有很多类似药物反应，预防方法是将药物相互反应输入电脑，当医生开具处方时，就会有警告提示当前药物和患者已服用药物相互作用，并给出进一步推荐。有很多关于这方面讨论，在美国是很热门的话题。一些药物可引起心电图改变，可能导致危险甚至致死性心律失常。因此应当对这些药物相互反应非常小心。