International Circulation: The incidence of AF is increasing with the patient age， at the same time， the bleeding risk of anticoagulation is increasing in the elderly. In clinical practice， how do we weight efficacy and safety of anticoagulation therapy for preventing stroke? How do we choose optimal antithrombotic agents aimed at different patients?
　　《国际循环》：随着患者年龄增长，房颤的发病率增加，抗凝治疗的出血风险也增加。在临床实践中，为预防卒中，我们如何权衡抗凝治疗的疗效和安全性？对于不同的患者，我们如何选择最佳的抗凝药物？
　　Dr. Ezekowitz: When you consider anticoagulation， you always have to weigh the benefit against the risk of bleeding. The aging population tends to have atrial fibrillation related strokes which have a high mortality and a high morbidity and， to a large extent， these are preventable. This needs to be weighed up in making this decision. The decision to anticoagulate a patient is a judgment call; it’s a fine line to walk， but the strokes associated with atrial fibrillation are devastating. Anticoagulation， particularly with the new agents， is highly effective and one shouldn’t lose sight of that.
　　Based on clinical trials， for the patient population as a whole， dabigatran is more effective than well-controlled warfarin. There is a 35% reduction in stroke and systemic embolization and a 7% reduction in major bleeding with a massive reduction in intracranial hemorrhages. Having said that， not all patients are candidates for dabigatran - if the creatinine clearance is below 30， they are not candidates; children are not candidates; pre-menopausal women who are not on adequate contraception are not candidates; and patients with mechanical heart valves are not candidates.The elderly are difficult to manage because they are at a high risk for stroke but also they are at higher risk for bleeding， particularly GI bleeding.
　　Dr. Ezekowitz：当考虑抗凝治疗时，必须权衡获益和出血风险。人口老龄化，伴随着与房颤相关的卒中增加，其发病率和死亡率高。然而，在很大程度上，这种状况是可预防的。在作出决定时，需慎重权衡。对患者进行抗凝治疗的决定是一种判断需求，虽容易掌握，但与房颤相关的卒中是毁灭性的。抗凝治疗，尤其是应用新型抗凝剂，高度有效，我们不应忽视这一点。
　　基于临床试验，对整个患者群体，达比加群较控制良好的华法林更为有效，卒中和体循环栓塞的风险下降35%，大出血的风险降低7%，主要是颅内出血大幅度地降低。 虽然如此，但并非所有患者都适合应用达比加群，如肌酐清除率＜30 ml/min的患者，儿童，未充分避孕的绝经前女性以及有心脏机械瓣膜的患者。老年患者因为卒中风险很高，出血风险更高，尤其是胃肠道出血，所以难于管理，用药尤应慎重。