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。
<International Circulation>: Thank you. When STEMI (ST elevation myocardial infarction) patients present later than 12 hours after the onset of symptoms， whether they can benefit from PCI or not is closely related to the existence of viable myocardium. How would you estimate viable myocardium rapidly and accurately in clinical practice?
Dr. Mehilli: If a patient has a myocardial infarction， it is difficult to put the patient in MRI or to do sestamibi accurately. Even if they are late comers， we take them to the Cath lab to open the artery. The measurement of viable myocardium is important at the end of the interventions. We can measure this with the technetium sestamibi， which is effective but means more radiation for the patient. We use just MRI to measure not only the infarct type， but also the peri-infarct edema. This is the part of the myocardium， which can be salvaged during during the weeks and months after the intervention.
《国际循环》：如果STEMI患者起病12小时之后就诊的话，能否从PCI中获益是否与有无存活心肌紧密相关。临床实践中如何快速、准确地测定存活心肌？
Mehilli博士：对就诊的心梗患者很难实施MRI检查或司他比锝即刻进行评估，因为这些是急性心梗患者。因此，即使是就诊较迟的患者，我们也尽快将患者送入导管室并开通梗阻血管。在介入治疗的最后测定存活心肌是重要的，也就是估计梗死面积。司他比锝心肌灌注显像是测定存活心肌的一个非常好的方法，但是对患者的辐射多一些。我们也可以用MRI来测定，不仅可以确定梗死面积，还可以观察梗死灶周围的水肿。水肿区是在干预后数周乃至数月内可被挽救的心肌。
<International Circulation>: For my last question， in 2011 the ACCF (American College of Cardiology Foundation) and AHA (American Heart Association) SCA (sudden cardiac arrest) guidelines for PCI were modified. The time window of transfer PCI was modified from 90 minutes to 120 minutes. In your opinion， do you think the time window could extend again in the future and what do you think is the longest time window possible for primary PCI?
Dr. Mehilli: I hope that guideline authors would accept this tool and prolong the time from symptom onset to the intervention because it salvages myocardium and can save lives， even if you do it later after the symptom onset. The important thing for the patient is to be treated， because the later patients are higher-risk patients. They are often older or female patients with more co-morbidities， and this part of the population would benefit from the intervention， independent of when the arteries are occluded. Every time we can win something. That is why I would hope that this window will be expanded. We cannot say there is a time in which you cannot do PCI. With PCI you can open the artery in more than 90% of the cases. Sure， there are low risk patients in with just one diseased artery and the natural collaterals have been developed. Patients， for example like in the OAT trial， are low risk patients. These patients are symptom free， with no sign of ischemia and perfect collateralization. For them， no PCI is needed. However， these patients are rare.
《国际循环》：2011年，美国心脏病学会基金会/美国心脏协会（ACCF/AHA）修订了PCI猝死指南。转运PCI治疗时间窗从90分钟延长至120分钟。未来这一时间窗是否会再次延长？你认为直接PCI最长的治疗时间窗可能是多少？
Mehilli博士：我期望制定该指南的同仁能够延长从发病到PCI干预的时间窗，因为PCI能够挽救心肌和生命，即使是在发病较长时间后实施PCI的情况下。对于患者来讲，重要的是得到治疗，因为发病后较晚就诊的患者属于高危患者。他们通常年龄较大或是有更多并存疾病或是女性患者，这些患者能够从PCI治疗中获益，无论他们的动脉是什么时候阻塞的。每一次PCI干预都能够有所收益。这就是我期望PCI治疗时间窗能够延长的原因。我们不能说发病超过一定时间就不能做PCI了。PCI可以使90%以上的患者动脉开通。当然，有一些单支动脉闭塞的低危患者，有侧枝供应。例如OAT（闭塞动脉试验）中的患者就是低危患者。这些患者如果没有缺血症状的话，可能不需要实施PCI，只给予药物治疗即可。但是这只是极少一部分患者。
<International Circulation>: Alright， thank you very much.
Dr. Mehilli: You’re welcome.
[下一页] [1] [2]