International Circulation: What are your suggestions for LMWH application in ACS? Compared with heparin， what is the advantage of LMWHs?

《国际循环》：您对低分子量肝素在急性冠脉综合征（ACS）中的应用有何建议？与肝素相比，它的优势是什么？

Prof. Nicolas Danchin: Low molecular weight heparins have been used very widely now in patients with acute coronary syndrome but using different doses and I think it is important to adjust the dose according to the age of the patient and their renal function as well. If you do that， it seems that the results achieved with LMWHs are superior to those of unfractionated heparin and there is little increase in the bleeding risk if you adjust the doses as I said. If you do not adjust the doses， you have a somewhat larger increase in the bleeding risk when you use LMWH compared to unfractionated heparin. But on the whole， I think the evidence is that you can reduce the ischemic complications using LMWH compared with unfractionated heparin. It should now probably be the reference treatment for patients with ACS.

Danchin教授：低分子量肝素目前在急性冠脉综合征中的使用已非常广泛，但个体使用剂量有所不同，我认为重要的是要根据患者的年龄和肾功能调整剂量。如果你做到这一点，低分子量肝素是优于普通肝素的，如果你照我所说的调整剂量，几乎不会增加出血的风险。如果你不调整剂量，低分子量肝素较普通肝素有较大出血风险。不过总体而言，我认为使用低分子量肝素相比普通肝素可以降低缺血性疾病的并发症。目前低分子量肝素是ACS患者的推荐治疗。

International Circulation: At present， there are many kinds of LMWHs， would you like to introduce the differences among these LMWHs? Does Nadroparin Calcium have any advantage in ACS treatment over other LMWHs?

《国际循环》：目前有多种低分子量肝素，您能介绍一下几种低分子量肝素之间的区别吗？那屈肝素钙在ACS治疗上是否比其他低分子量肝素有优势？

Prof. Nicolas Danchin:There are many LMWHs and in the context of ACS it is essentially enoxaparin which has been studied in the greatest number of trials. Nadroparin has been studied as well， but the main results have been achieved with enoxaparin.

Danchin教授：现在有多种低分子肝素，在治疗ACS方面依诺肝素是研究最多的一种。那屈肝素也有相关研究，但主要是关于依诺肝素的研究比较多。

International Circulation: In your opinion， should high-risk patients receive anti-thrombotic therapy?

《国际循环》：您认为高风险患者是否应该接受抗血栓治疗？

Prof. Nicolas Danchin: When we speak of high-risk patients， it is important to determine if it is high-risk in primary prevention or high-risk in already known coronary artery disease. If it is high-risk in patients with already known coronary artery disease， they should have anti-thrombotic therapy. They should have aspirin and they should most probably have combination with clopidigrel or a newer thienopyridine for one year after ACS because this is the period when they are at the highest risk. For primary prevention， the benefit of aspirin is found essentially in patients in the high end of the cardiovascular risks， that is， if they have a cardiovascular risk of more than 5%. Aspirin reduces the risk of cardiovascular events to a larger extent than it increases the risk of gastro-intestinal bleeding so the benefit-harm ratio is good for aspirin. If you are at high-risk in primary prevention， aspirin therapy is advisable.

Danchin教授：当我们谈到高风险患者，重要的是要确定是高风险的一级预防还是已知有冠状动脉疾病的高风险患者。如果是已知患有冠状动脉疾病的患者，需要抗血栓治疗。他们应该在ACS 后服用阿司匹林，可能需要同时联合服用氯吡格雷或新的抗血小板药物噻氯匹啶持续1年，因为这是风险最高的一段时间。对于一级预防，阿司匹林对心血管疾病危险超过5％的高危人群而言是必须的。比起增加胃肠道出血风险，阿司匹林更大程度上降低心血管事件发生风险。因此使用阿司匹林还是利大于弊。如果你用于高风险的一级预防，阿司匹林治疗是可取的。

International Circulation: How do you reduce the risk of bleeding in antithrombotic therapy of high-risk patients? Are the new antithrombotic agents like fondaparinux helpful?

《国际循环》：您如何减少高风险患者抗血栓治疗引起的出血危险？新型抗血栓药物磺达肝癸钠能否减少出血风险？

Prof. Nicolas Danchin: There are new anticoagulants such as fondaparinux， that is true， that have been studied in patients with ACS. The problem with fondaparinux is it was studied in a large trial where the use of PCI was rather on the low side and what was found was that， overall in the trial， the effect of fondaparinux was beneficial. There was a reduction in the coronary events and a reduction in mortality in the trial. This was clearly linked to a reduction in the bleeding complications. However， the downside of this is that it seems fondaparinux is not really appropriate in the patients who have rapid PCI because it is a slightly less potent anticoagulant. There were more catheter thrombi in the group of patients who received fondaparinux than the other antithrombotic agents.

Danchin教授：的确，新的抗凝药磺达肝癸钠已用于ACS患者进行临床研究。问题是磺达肝癸钠的大规模临床研究都是在PCI患者中使用，从试验总体来看，磺达肝癸钠是有益处的。试验研究发现，使用磺达肝癸钠可减少冠状动脉事件的发生率和死亡率。这显然与出血并发症减少有关。但缺点是，磺达肝癸钠似乎对急诊PCI患者术后的抗凝并不合适，因为它起了轻度的、潜在的抗凝作用。在急诊PCI患者中磺达肝癸钠组出现导管内血栓的发生率比其他抗凝血剂组多。

International Circulation: Could you talk about the rapidly evolving management of ACS? What are the hot topics in this field， especially in the strategies of anticoagulation?

《国际循环》：您能谈谈ACS的急诊处理吗？在这一领域的热门话题是什么，特别是在抗凝方面？

Prof. Nicolas Danchin: It is fast-moving and it is difficult because all things move at the same time. So at the same time you have several trials examining different questions with different reference treatments. At the end of the day， you don’t know where you are at all. That’s the difficulty in managing ACS and antithrombotic treatment. Overall at present， what is certain is that it is beneficial to have a dual anti-platelet therapy with aspirin plus another anti-platelet agent， which might be clopidogrel or which might be a newer agent such as prasugrel or such as ticagrelor. The situation is less clear for anticoagulants where， in my mind， you have the choice of either: LMWH; bivalirudin， which is more or less the same as heparin plus GPIIb/IIIa inhibitors; or fondaparinux as well， in the patients who are at high risk of bleeding. You have to look at the profile of the patients and try to determine what is the best anticoagulant therapy but I must say it is very difficult to know， because there has never been a head-to-head comparison of enoxaparin or LMWH， fondaparinux and bivalirudin， comparing all three medications together on a background of dual anti-platelet therapy. This has not been done and this probably should be done in the future.

Danchin教授：这个领域发展迅速但也存在着困难，因为事物是在同步发展的。目前有不同的临床试验针对不同的问题研究不同的处理。最终，你可能不知道到底该如何处理，这是ACS处理和抗血栓治疗的难点。总体而言，目前可以肯定的是，双重抗血小板治疗是有益的，使用阿司匹林加另一种抗血小板药物如氯吡格雷或更新的药物，如普拉格雷或替卡格雷。抗凝治疗的局面目前并不十分明了，我认为可选择以下几种抗凝药物：低分子量肝素，比伐卢啶，相当于肝素加糖蛋白IIb / IIIa抑制剂两者相加的效果，磺达肝癸钠可在出血风险较高的患者使用。必须根据患者的实际情况来决定选择最佳的抗凝治疗方案，但我必须说，这很难比较，因为从来没有一个在双重抗血小板治疗的背景