Julinda Mehilli  德国慕尼黑Technischen大学

　　<International Circulation>: Saturday August 25th at the ESC 2012 in Munich. with Dr Mehilli following her session. Dr. Melhilli， according to your article published recently in JCC (Journal of Cardiology) the subgroup analysis ISAR-REACT-4 showed that there was a significant difference in the outcomes between patients with and without high platelet reactivity who are treated with bivalirudin. What is your opinion on performing routine platelet function tests in ACS (acute coronary syndrome) treatment?
Dr. Mehilli: I come from an institution where routine platelet function testing was established from the beginning. Since 2004， we perform a routine examination on each patient undergoing diagnostic categorization for interventional procedures. We do believe that with monitoring platelet function we can better tailor the therapy in patients undergoing intervention， particularly ACS patient. ACS patients have very aggressive platelets with high thrombotic events， even after a successful PCI. That is why it is important to identify patients who are resistant to clopidogrel， or even to the newer P2Y12 receptor inhibitors. In ACS patients， if you give clopidogrel， nearly 30% of them are resistant to clopidogrel and even with prasugrel， up to 5% have high platelet reactivity. We need to tailor the therapy using platelet function testing， particularly in times when using bivalirudin to reduce the bleeding complications in patients with acute coronary syndrome. We have to be aware that in the first phase of the intervention， - the peri-interventional stage - there is likely more thrombotic milieu in the patient receiving bivalirudin. This sub-study from the ISAR-REACT-4 trial did show that， in bivalirudin treated patients， it is important to have a very potent P2Y12 receptor inhibitor. Clopidogrel alone will not be enough. You know the results from the TRITON-TIMI 38 study in which prasugrel was better than clopidogrel in ACS patients and I think the patient treatment in the REACT-4 trial will be modified， because if we give bivalirudin we need to have also prasugrel or ticagrelor on board.

　　《国际循环》：Melhilli博士，根据你最近在心脏病学（JCC）发表的ISAR-REACT-4亚组分析结果，接受比伐卢定治疗的血小板反应性高和不高的患者转归有显著差异。你如何看待在ACS患者常规检测血小板功能？
Mehilli博士：我所在的医疗机构已经开始常规检测血小板功能。从2004年开始，我们对诊断、干预或接受操作的每一位患者常规检测血小板功能。我们认为，监测血小板功能可以让我们对接受干预的患者更好地进行个体化治疗，尤其是ACS患者。ACS患者的血小板非常活跃，发生血栓事件的风险高，甚至在成功实施PCI后风险仍高。因此，发现对氯吡格雷甚至是更新型的血小板P2Y12受体抑制剂耐药或抵抗是重要的。在应用氯吡格雷的ACS患者中，有接近30%的患者有氯吡格雷抵抗，即使是用普拉格雷的话，仍有5%的患者血小板反应性仍高。对这样的患者，我们需要根据血小板功能检测的情况进行个体化治疗，尤其是目前研究显示应用比伐卢定有不错的结果，能够减少ACS患者的出血并发症。我们尤其要注意在干预的早期，即围介入手术期，应用比伐卢定的患者血栓风险略有增加。ISAR-REACT-4研究亚组研究显示，服用比伐卢定的患者应用非常强的血小板P2Y12受体抑制剂是至关重要的。氯吡格雷不够强效。TRITON-TIMI 38研究显示，普拉格雷用于ACS患者优于氯吡格雷。我认为ISAR-REACT-4研究ACS患者的治疗应当做出更改，如果给予比伐卢定的话，同时要给予普拉格雷或替格瑞洛。

<International Circulation>: What are the differences between patients with high platelet reactivity (HPR) and non-HPR patients in regard to antithrombotic therapy?
Dr. Mehilli: The difference is that the patients with high platelet reactivity are patients at very high risk for thrombotic events. They have 4 times more central thrombosis than the patient who is responsive to clopidogrel or responsive to P2Y12 receptor inhibitors.  The patients with high platelet reactivity who have more peri-interventional infarction are patients who are at higher risk of death than the patient who responds well to clopidogrel or prasugrel.

　　《国际循环》：血小板反应性高（HPR）和血小板反应性不高的患者在抗栓治疗方面有哪些不同？
Mehilli博士：区别在于血小板反应性高的患者发生血栓事件的风险非常高。这些患者比对氯吡格雷或其他血小板P2Y12受体抑制剂有反应的患者血栓风险高4倍。血小板反应性高的患者围术期心梗发生率高，发生死亡的风险也更高。