International Circulation: What do you think that PARIS adds to the conversation on Dual Anti-Platelet Therapy (DAPT)?
Dr. Roxana Mehran: As the principle investigator， I have an obvious conflict of interest regarding PARIS， and it may be good to talk to other. However， for the very first time， we have a novel finding in thinking of DAPT not as an on-and-off switch by rather what was the circumstance by which the switch was turned off or why did it go back on. We collected that data prospectively， not retrospectively in large registry of real-world patients. We found that different modes of adherence have different outcomes on the patients and different implications. For example， if you abruptly stopped DAPT without physician guidance， there is a higher rate of major clinical events. Under physician guidance， even with earlier interruption or discontinuation， was not associated with important clinical outcomes. It brings back confidence that if a cardiologist is closely monitoring the case， guiding the patient through their options， outcomes can turn out well. Importantly， PARIS included a larger number of second-generation drug eluting stents that are， in general， safer than first generation. I think that is an caveat regarding PARIS. This is a contemporary approach because， in this current generation of drug-eluting stents， we are seeing low event rates and when you reduce， stop， or interrupt under the guidance of a physician， you’ll be ok. That is an important message that has not been seen before and we are going to follow this out for two years.
《国际循环》：您认为PARIS试验对双联抗血小板疗法（DAPT）的讨论有什么影响？
Mehran教授：作为首席研究员，我谈论PARIS会有明显的利益冲突。不过，这是第一个试验探讨DAPT在什么样的情况下要停止，什么情况下要恢复，而不仅仅将DAPT作为一种可停可续的方法。这个注册研究在真实世界患者中，前瞻性地而不是回顾性地收集数据。我们发现不同模式的依从性的结果不同，意义也不同。例如，如果患者在没有医生指导下，突然停止DAPT，主要临床事件的发生率升高很多。但在医生指导下，即使早期中断DAPT，临床结果也没有什么变化。我们有信心说如果心脏科医生密切监督指导患者减用或停用DAPT，仍会有好的临床结果。PARIS研究大量使用的是第二代的DES，总体来说优于第一代的DES，这可能是原因之一。我们看到，当代的DES事件发生率较低，当患者在医生指导下减量、停止或中断DAPT时，患者会没事。这种情形以往从未得到报道，我们将持续随访2年。
International Circulation: In less well-financed hospitals that may not have access to second generation stents， would you still suggest the same level of caution?
Dr. Mehran: Absolutely. Everyone has access to second generation stents. In fact， first generation stents are also extinct in the US. In China， there has to be tremendous oversight for the first generation of drug-eluting stents through the physician guidance. It is important think about that as well.
《国际循环》：很多经济不发达地区还没有第二代支架，您的建议是？
Mehran教授：医生对置入第一代支架的患者，应非常非常注意，应更为密切地指导患者。
International Circulation: The PARIS trial may give confidence to doctors who are considering taking their patients off of DAPT. Do you have any personal tips for these doctors?
Dr. Mehran: When it comes to first generation drug-eluting stents， I would not consider discontinuing therapy for at least the first six months. It should be an important circumstance. With the second generation， we have good enough data to show that beyond three months you can interrupt them under your guidance to watch them through a non-cardiac or surgical procedure when interrupting their DAPT. There are certain cases where you know that the bleeding complications are high， like in the elderly， in females， in small sized peatients. You do not want them to be taking these even with minor bleeding episodes. You are concerned they may not be compliant. It is best to think about those patients and consider discontinuing therapy in these patients if everything else equal. With that being said， this puts an underling importance on a randomized study. Before that， these are just observational， hypothesis-generating data. I do not think we can give any clear recommendations. We can only suggest that physicians are extremely important in the decision whether or not to stop duel antiplatelet therapy.
《国际循环》：PARIS研究可能带给医生信心来停用DAPT。您有什么建议给这些医生？
Mehran教授：我认为第一代DES至少要使用6个月的DAPT，这一点很重要。对第二代DES而言，我们有足够好的证据说明3个月后，如果需要外科手术，在医生的指导下，可以中断DAPT。有些患者出血风险很高，如老年人、女性或体重低的患者。医生可能不希望这些患者长期服用DAPT，甚至在一些小的出血事件时。这些患者还可能依从性差。对这些患者，如果其他情况没有异常，最好考虑停药。尽管我这样说了，但重要的是进行一项随机试验，在此之前，所有的数据都是观察性的、产生假设的。我不认为能够给予确切的推荐，我们只是建议医生在决定是否继续DAPT上的重要作用。
International Circulation: With the elderly， what extra considerations would you make for DAPT treatment?
Dr. Mehran: The elderly are extremely prone to major bleeding that may be minor for younger populations. It is very important to follow those patients， to think about how to apply non-bleeding or bleeding-protective therapies on those patients， because bleeding is extremely important. A bleed can kill these patients. We also do not want to be vigilant that we actually ration care to them and not give them life saving therapy. There is a fine balance between the risks and the benefits for those patients.
《国际循环》：对老年患者，DAPT有什么特殊之处吗？
Mehran教授：老年人出血风险高于年龄教轻者。对老年患者坚持随访很重要，还应该考虑使用出血保护或不出血的方法。出血是一件很严重的事，可致人死亡，我们愿意尽一切可能以避免这种后果。但我们也必须不过份紧张，不给予他们可以挽救生命的治疗（DAPT）。在获益和风险之间要找到最佳平衡点。
International Circulation: As a physician trying to understand the risks and benefits， though have no trials that focus on elderly patients， how do you apply the data?
Dr. Mehran: It is difficult， because at the end of the day， both the elderly and women comprise a minority. We do not have enough data and need more disparity data. The elderly belong in the disparity group. We have to promote the inclusion of these patients. Otherwise， you have to use your clinical judgment. It is the art of medicine.
《国际循环》：大多数的临床使用没有纳入老年患者，医生该如何寻找最佳平衡点呢？
Mehran教授：这确实很困难。老年人、女性是少数，我们没有足够的数据，但我们需要这些不同人群的数据。我们必须推进在临床试验中纳入老年人，纳入女性。在目前缺乏证据的情况下，医生只有运用自己的判断，这是医学艺术。
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