[CIT2013]稳定性冠心病的最佳临床决策——美国哥伦比亚大学Ajay J. Kirtane教授专访
Ajay J. Kirtane教授 美国哥伦比亚大学
<International Circulation> : And what did you want to add in the appropriateness guidelines that you did not see?
Prof. Ajay: I think mainly more granularity so more specific scenarios and overall patterns of use. One of the things that has been well documented is that there is a wide variability in terms of practice and by essentially coming up with a group of standards of criteria that make things more appropriate or uncertain or even perhaps inappropriate you could then somehow， if you average across patients and physicians， come up with more reduced variability.
《国际循环》：您想在未曾用过的适用指南中加入哪些内容？
Ajay教授：我认为应该加上更具体的方案和更整体的应用模式，以使其更精细化。目前已知的是，临床实践存在很大的变异性，如果能够制定一组更合适的标准则有助于降低其变异性。
<International Circulation> When it comes to making clinical decisions for the treatment of coronary heart disease there are a couple scores going on like the syntax score or the Euro score. Should we be basing our decisions based on anatomical parameters or clinical parameters?
Prof. Ajay:I think both. Whenever we treat a patient it is not only what they look like but also what their coronaries look like as well and it is really the integration of those two things together that help inform patient care and I think Patrick Serruys today presented some data on SYNTAX 2 and that does exactly that， incorporated the two together and amalgamating them to be able to then treat patients better.
《国际循环》：选择冠心病治疗决策时常用的有Syntax评分和EURO评分。我们应该根据解剖学参数还是临床参数来做治疗决策？
Ajay教授：我认为选择冠心病的治疗决策时应同时参考解剖学参数和临床参数。无论何时我们对患者进行治疗时，不仅仅要看患者的临床表现，还应该注意其冠脉的情况，应该将两者整合在一起以确保为患者提供更好的服务。我认为，Patrick Serruys教授报告的有关SYNTAX2评分的相关数据提示，将两种参数整合有助于实现对患者更好的治疗。
<International Circulation> : And so in your practice， which aspects do you take from these scores that you consider most important?
Prof. Ajay: You know it is not so much the number or the score itself， it is more the parameters that factor into it. So if for instance if someone has very complex disease then that might favor a surgical approach because it is too complicated for a PCI. However， if a patient is very elderly and has clinical parameters， which would make surgery too high risk， then you could accept a higher anatomic score at which you would do PCI. So a lot of times， clinicians and good clinicians would feel the need to calculate scores. They can look at the patient， and look at the anatomy and come up with the criteria which would help devise which way to treat them but I think overall， the scores objectify some of that reasoning and especially if you apply it to populations you would also reduce variability in practice.
《国际循环》：在您的临床实践中，您认为上述评分中的哪些因素最为重要？
Ajay教授：你知道上述评分的数量本身并不是太多，但其中涉及的参数却非常多。例如，如果患者存在复杂病变，难以行PCI治疗时，可能更适合行手术治疗。但是如果患者是老年人，并具有较高手术风险的临床表现，则虽然其解剖学评分较高但仍需行PCI治疗。因此，很多时候，临床医生会觉得需要计算患者的评分。他们可以通过查看病人临床表现及其解剖学参数，从而确定治疗方式。但是，我认为总体而言，评分过程需要客观的推理，尤其是当你将它应用于人群中的时候，你需要降低其实践中的变异性。
<International Circulation> : What factors should we take into account on individualizing therapy for revascularization and how do we get the best clinical results?
Prof. Ajay: A few things， number one is the symptomatic status of the patient. So really how symptomatic they are but it goes beyond asking them， you also have to ask them what they do， so somebody who does not ever get off the couch may be symptomatic if they did whereas someone who can run a marathon is clearly not that symptomatic. Number two is how adequate their medical therapy is. Are they actually taking their medicines regularly and do those medicines help them but then I think more important to sort of all these things are what the disease actually is. Is it left main， is it a side branch of another vessel， and those things will really impact what you offer the patient because left main， even if the patient is asymptomatic you might still offer revascularization whereas if it is a small branch of the circumflex， if they are very symptomatic you might still do revascularization. If they are less so then you might push the medicines.
《国际循环》：对患者进行个体化的血运重建治疗时应考虑哪些因素？如何才能达到最佳的临床效果？
Ajay教授：需要考虑几个因素。首先，是患者的症状。要想确定患者的状况如何，这不仅仅需要对其进行问诊，还需要详细地询问他们都做些什么。那些从来都坐在沙发上的患者可能当其离开沙发时就会有症状，而那些能跑完马拉松者则不会这样。其次，是药物治疗是否足量。患者是否真正接受了常规药物治疗，这些药物是否对其真正有帮助。最重要的是，疾病到底是什么。是左主干病变？还是另一支血管的侧支病变，这些都会影响你对患者的治疗决策。因为左主干病变时即使患者没有症状你仍需要进行血运重建。而如果是回旋支小的分叉病变且患者伴有严重症状才需要进行血运重建，如果症状不重，则可以行药物治疗。