<International Circulation>:  How risky is that chance?
   《国际循环》：这样的可能风险有多大？
    Prof. Weitz:  You have the number of 10% risk at one year and 30% at five years.  When I talk to patients whose initial even was a pulmonary embolism， 60% of such patients their recurrent event will also be a pulmonary embolism.  The case fatality rate is higher with pulmonary embolism than it is with deep VT.  For someone who has had a massive pulmonary embolism I would not be in any rush whatsoever to stop their anticoagulant therapy.  For someone who had a deep VT it may be considered.  It is necessary to explain the risks and if they stop they have to be very vigilant， any time they have pain， micro swelling， or pain in their chest， then they have to be investigated.  For some patients， say a businessperson who is traveling a lot， they don’t want to take the chance of having something happen while they are in some other country and not know what to do.  Just for their peace of mind they would want to stay on long-term anticoagulation.
    Weitz教授:你已经听说了这两个数字：一年10%风险，五年30%的风险。对于跟开始即因肺栓塞就诊的患者，我往往告知他们有60%的复发事件为肺栓塞。肺栓塞的死亡率比深静脉血栓高。对于某些患有大面积肺栓塞的患者来说，我不会急于停止他们的抗凝治疗。有必要向他们解释这种风险而且一旦他们停止抗凝治疗，他们就不得不非常谨慎，任何时间出现的疼痛、微笑肿胀或者胸痛，他们都不得不接受检查。对于某些患者来说，比如说一个经常旅行的商人，他们不想在其他国家发生一些事情以及不知道如何处理。仅仅为了安心，他们会选择坚持长期抗凝治疗。
 
    <International Circulation>: Then there is still the risk of bleeding， which is also a concern.
   《国际循环》：但是出血的风险仍然存在，还应该考虑什么因素？
    Prof. Weitz:  Correct， but at least in the study setting the overall risk after having completed three or six months of anticoagulant， if one hasn’t already bled already， is probably fairly low.  Patients with unprovoked VTE are typically a younger population， like those with atrial fibrillation that you are hearing about in RELY and ARISTOTLE and ROCKET.  In general， the risk of major bleeding with warfarin is somewhere around 1%.  The risk of recurrent VTE is higher.  Balancing the rates of risk of fatal VTE or PE with bleeding is about easier since they are both about 1%， although fatal bleeding with warfarin can occur.  This is why we are interested in the newer anticoagulants because at least the intracranial hemorrhage rates seem to be lower with these agents than with warfarin， plus they are simpler.  If we are going to commit these patients to extended treatment then it would be nice to have simpler therapy.  Having the results from the AMPLIFY Extension study， it is possible， after a treatment course with usual intensity anticoagulants， to reduce the dose to get a better benefit to risk profile.
    Weitz教授:正确。但是至少在本研究的环境中，经过3个月或6个月的抗凝治疗后，如果该患者从来没有过出血史的话，总的出血风险是相当低的。患有不明原因VTE的患者人群是年轻的人群，就像你听说的在RELY 、 ARISTOTLE 和 ROCKET的房颤患者一样。一般来说，华法林总的出血风险在1%左右，复发性的VTE的风险更高。致命性静脉血栓栓塞症以及伴出血的肺栓塞是较容易的，因为他们的发生率均在1%左右，尽管华法林可能会发生致命的出血。这就是为什么我买对新的抗凝药物感兴趣，因为至少这些药物的颅内出血发生率似乎比华法林低，而且他们的应用很简单。如果我们继续使这些患者延长治疗时间，采用简单的治疗更好。根据AMPLIFY Extension study的有研究结果，经过一个常规的强化治疗过程后，减少剂量以在降低风险方面获益是有可能的。

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