Gregg W. Stone， MD， FACC， FSCAI
　　哥伦比亚大学医学中心/纽约长老会医院心血管病研究和教育署署长。Stone教授是世界顶尖介入心脏病学家之一，TAXUS IV药物洗脱支架临床试验的主要研究者。

　　International Circulation: It is well known that the benefits and risk of bleeding associated with oral antiplatelet agents for agents for acute coronary syndrome (ACS) or in patients who have undergone PCI. According to guideline recommendations， how to help health care providers make informed decisions regarding of the most appropriate therapy for patients after ACS and PCI?
　　国际循环：众所周知，对于急性冠脉综合征（ACS）或者接受经皮冠脉介入治疗（PCI）的患者来说，口服抗血小板药物带来的益处与出血的风险并存。根据指南的建议，应该如何协助卫生保健的提供者做出明智的决策，为ACS患者和接受了PCI手术的患者选择最适当的疗法？
　　Prof. Stone: Thank you for the question. It is very important in this regard to realize what it is that you are trying to do with pharmacotherapy. It is not starting agents for the sake of starting agents， but we’re trying to get patients through the PCI procedure and keep their stents. If you implanted stents through thrombosing and keep them from having new plaque ruptures if they become symptomatic and provide long-term stability， basically for the coronary tree as well as for any other vascular disease. In that regard， in the short term， we have seen that there is an important balance between bleeding， hemorrhagic complications and ischemic complications that we have to consider. These agents are designed to prevent ischemic complications but can cause iatrogenic bleeding. Iatrogenic bleeding can overcome any benefits from ischemic complications. We have to suppress ischemia without the patient exsanguinating. In this regard， there have numerous studies in which bivalve routing seems to be safer and more effective than heparin and glycoprotein IIb/IIIa inhibitor. In the right kinds of patients， the more potent ATP antagonist ticagrelor in particular seems more effective than clopidogrel. Those patients are mostly those with acute coronary syndrome. Lower risk patients， such as those with stable coronary artery disease do not benefit as much from that potent ADP antagonism but are all exposed to the same risk of bleeding so they should be just treated with more standard doses of clopidogrel.
　　Stone教授：首先，非常感谢您的提问。在这一方面，了解自己想通过药物疗法达到什么目的是非常重要的。我们并不是单纯为了用药而用药，而是为了协助患者接受PCI治疗并维持他们的支架。如果患者出现症状，我们在血栓形成的位置植入支架，防止患者出现新的斑块破裂并提供长期的稳定性，基本上为了防止冠状动脉树和其他血管疾病的发生。在这方面，我们需要在短期内考虑到出血风险，出血并发症和缺血并发症之间存在的重要的平衡点。这些药物是用来防止缺血性并发症的，但是能够引起医源性出血。医源性出血会抵消预防缺血性并发症带来的任何益处。我们需要在患者不出血的情况下防止局部缺血。考虑到这一点，有许多研究显示双瓣途径似乎比肝素和糖蛋白IIb/IIIa抑制剂更加安全和有效。在特定的患者群中，较强效的ATP拮抗剂尤其是替卡格雷，似乎比氯吡格雷更有效。这类患者主要是急性冠脉综合征的患者。低危患者，如稳定的冠状动脉疾病患者，不能从强效ADP拮抗剂的使用中获得同样高的受益，但是却具有同等的出血风险，所以让他们接受标准剂量的氯吡格雷疗法就可以了。