IC: What is the best way to evaluate the cost-effectiveness of rhythm control and heart rate control with anticoagulant treatment? Especially as it relates to new treatments like closing off the LAA?
　　《国际循环》：什么是评估节律、心率控制与抗凝治疗成本-效益的最好方法呢？尤其是当涉及到封堵左心耳这样的新型治疗方式时？
　　Dr. Valderrabano: The best way is to have a randomized trial and then compare the costs. When are looking at device treatments to close the appendage， you have a very high up-front cost. You have to look five-years to see whether the strokes you prevent justify the cost of the procedure， the device， and the risk of re-hospitalizations. I am not convinced that these devices are going to overall better. It is an intriguing and worthwhile question. If you come up with a device that can both see the appendage and reduce the risk of stroke， then it will be justified. Some experts talk about combining an ablation procedure for rhythm and symptom control with a LAA plug. That may be the future.
　　Valderrabano博士:最好的方法是进行随机试验，然后比较成本。进行封堵心耳的治疗需要非常高的前期投入成本，必须观察数年以评估脑卒中预防的程序、装置费用以及再入院的风险是否合理。我不确信这些设备是否更优化，这是一个既有趣又有价值的问题。如果你想出一个装置既能处理心耳又可以降低卒中的风险，那么这将是合理的。一些专家在谈论导管消融结合LAA封堵用于控制节律及症状，这可能是未来的方向。
　　IC: What about today， what is the most cost-effective way to treat AF now?
　　《国际循环》：那些现在什么是最划算的治疗房颤的方式呢?
　　Dr. Valderrabano: In my personal practice， what I do may not be the most cost-effective but it does achieve the most patient satisfaction. If there are symptoms， I start with drugs. However， a drug’s efficacy depends on achieving sinus rhythm， if it does not do that， then you are wasting your time and may result in potential toxicity. Ablation is what I do most commonly for rhythm control and symptom control. In patients that are high-risk for stroke， they must be on anticoagulants. I try warfarin first for several reasons. If you have a good system for mainting the INR in therapeutic range， warfarin is as good as dabigatran. This has been shown in a subset of the RELY trial in centers in which the time in therapeutic range was more than 75%. There was no difference between dabigatran and warfarin. Warfarin in very cheap and though you have to control the INR， there are ways to achieve this. You may have to purchase a portable INR monitor. It is only a matter of time before these become cheap. In the US， because of insurance reasons， many will not allow dabigatran as a first line of therapy or will ask for a significant co-pay from patients， up to $600 a month. In the US system， the individual providers and insurers will have to negotiate with the drug companies to come up with a devicing scheme that is worthwhile. When these drugs come out of patent， they will be the first choice.
　　Valderrabano博士:在我看来，我做的可能不是最划算的，但确实使大多数患者满意。对于有症状的房颤，我建议最开始使用药物，然而一种药物的有效性取决于转复窦性心律，如果达不到，那就是在浪费时间，并可能导致潜在的毒性。导管消融是我最常做的控制节律和症状的治疗，且房颤患者卒中风险极高，必须同时使用抗凝剂。首先选择华法林有几个原因：如果有一个好的系统能够将INR维持在治疗范围内，华法林的抗凝和达比加群同样优秀，这已经在RELY试验的亚组研究中被证实，该试验中达比加群和华法令治疗范围内时间比例没有区别，都超过了75%。华法林的价格很便宜，但必须控制INR，目前购买一个便携式INR监测仪可以帮助实现INR达标，只是需要时间等待仪器降价。在美国由于保险的原因，许多人将不允许使用达比加群作为第一线的治疗，或要求患者自付高达600美元一个月的费用。所以美国的个人供应商和保险公司将不得不与制药公司谈判设备相关计划，这是非常值得的。而当这些药物专利到期后，会将成为他们的第一选择。

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