Roxana Mehran， MD， FACC， FACP， FCCP， FESC， FAHA， FSCAI，是西奈山医学院Zena and Michael A. Weiner心血管研究所介入心血管和临床试验部主任和医学教授。
　　International Circulation: The duration of dual antiplatelet therapy (DAPT) after ACS is still recommended as twelve months by current guidelines. We don’t have data available for DAPT continuation after that time but what is your gut feeling about the duration of DAPT in these circumstances?
　　Dr Mehran: I think the question of DAPT comes back to the patient and that we really do need to risk stratify the risk-benefit that that you gain or lose with prolonged dual antiplatelet therapy. Certainly， we know from a lot of the studies and in particular， PCI-CURE， that for ACS patients on aspirin plus clopidogrel， DAPT was so much better than aspirin alone in reduction of death/MI/CVE. Obviously through that， now we have had this translated into our guidelines. While we are all excited about this， we always have to understand that when we prescribe these kinds of prolonged therapies with antiplatelet agents we are increasing the risk of bleeding complications. So much more of the attention now has been turned towards reduction of bleeding complications and the importance of bleeding complications. We have shown in multiple studies that bleeding， intraprocedurally during the PCI and any kind of bleeding that leads to transfusion (the types of bleeds that are major) have important implications on the patient’s longevity. It is important that when you make those decisions about the patient about the duration of antiplatelet therapy that you consider the risk profile of the patient especially if they are at risk for bleeding complications. The other issue involved is that what is even more important is that we know from a lot of registries and data from clinical trials， that patients who actually bleed stop taking their dual antiplatelet therapies that actually could protect them against ischemic complications. There is so much that happens in a bleeding patient that we can’t even come to terms with. As soon as a patient bleeds， they enter this new maze of different therapies that are not really prescribed – they stop their statins and don’t pay attention to their beta-blockers. We don’t understand why these things happen but they do. It is important to avoid bleeding as much as you can， but not at the expense of exposing that patient to higher ischemic risks. It comes back to the art of medicine and allows us as clinicians to practice medicine and think about the patient.
　　《国际循环》：当前指南仍建议ACS后双联抗血小板治疗（DAPT）的疗程为12个月。我们还没有将DAPT延长至12个月以后的证据。凭您的直觉，您认为对这类患者DAPT最佳的疗程是多久？
　　Dr Mehran: 我们再次提到患者的DAPT问题，我们需要对患者进行危险分层，平衡患者的风险-获益，明确延长DAPT疗程后我们得到什么，可能失去什么。当然，我们已从大量研究尤其是PCI-CURE试验中得知，ACS患者服用氯吡格雷加阿司匹林，即DAPT，比阿司匹林单药治疗更有效地降低了死亡/MI/CVE的发生率。显然，现在我们已将这些证据转化为指南建议。在对此感到兴奋的同时，我们还必须理解当延长抗血小板药物的疗程时，也增加了患者发生出血并发症的风险。当前我们更多的注意力已经转向出血并发症的重要性以及如何降低出血风险。多项研究已表明，PCI术中及各种类型的导致输血的出血（严重大出血）对患者寿命有着重要影响。因此当你对患者抗血小板治疗疗程作出决定时，你必须考虑患者的风险状态，尤其是是否存在出血风险。另一个甚至更为重要的问题是，我们从大量注册研究和临床试验数据中看到，的确发生了出血的患者停用了双联抗血小板治疗，而后者可预防缺血性并发症。在出血患者中发生的这种情况如此之多，以至于我们难以应对。一旦患者出血，他们就陷入实际上并未处方的其他疗法的困惑中——他们中止了他汀治疗，却对β受体阻滞剂视而不见。我们不能理解为何发生这种情况，但其的确客观存在。尽你所能去避免出血当然重要，但不应该以将患者暴露于更高的缺血风险为代价。
　　International Circulation: How do we identify the patients who are at risk of bleeding and who requires a longer duration of DAPT?
　　Dr Mehran:  There are several papers that have looked at the bleeding risk scores that are out there. We developed one for acute coronary syndrome patients based on data from the ACUITY and HORIZONS studies. That’s not the only risk; there are many other risk scores. There is the GRACE bleeding risk score and so on. We know who those patients are. You have this understanding of who that patient is (the “gestalt” if you will) as a clinician. There are well-designed risk scores that are reproducible and validated that one can use to make sound judgments about these types of cases. The question of duration of dual antiplatelet therapy is a very important thing. If I am a patient， I want to know how long I have to take this medication for. And we don’t really have a good answer. That to me is unconscionable in the field of medicine. Here we are giving medications without knowing for how long the patient actually needs it. There are studies looking at the length of therapy but I am more interested in saying， when can I stop， can I go and have my colonoscopy? There are bleeding complications that are not related to the heart per se and patients need to have other non-cardiac surgeries and screening processes for other conditions and the multitude of things that can affect a patient. We don’t know if we can stop their medication and restart it or even if they really need it. Future trials are going to be looking at shorter duration therapies so that we can say the course can be stopped and recommenced again when possible.
　　《国际循环》：我们应如何识别有出血风险的患者，以及哪些患者需要更长疗程的DAPT？
　　Dr Mehran: 已有多篇文献报告了不同的出血风险评分。基于ACUITY 和 HORIZONS研究数据，我们建立了一项用于急性冠脉综合症患者的出血风险评分系统。当然这不是唯一的，还有许多其他的风险评分方法，如GRACE出血风险评分等。作为医生我们应当掌握患者的情况。已有设计良好的风险评分，具有很好的可重复性，已被我们利用来对病例作出可靠的判断。双联抗血小板治疗的疗程时非常重要的事情。如果我是病人，我当然想知道自己需要服药多久。的确，我们还没有很好的答案，对我而言，在医学领域这是不负责任的，因为我们居然在不知道患者需要用药多久的情况下给病人处方这种药物。有很多研究评估用药疗程，但我更感兴趣的是，我何时可以停药？我是否可以离开，去做结肠镜检查了？有许多与心脏本身无关的出血并发症，也有很多患者需要接受非心脏手术和其他目的的检查，如此等等。我们不知道能否停药以及是否需要重新开始服药，甚至不知道他们是否真正需要这些药物。未来的临床试验将观察更短的疗程，届时我们将可回答可以停药，并再次做出建议。
 

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