International Circulation: On the topic of risk stratification， there is also a new bleeding score that has been introduced， CRUSADE. What is your experience with this score?
　　《国际循环》：关于危险分层，有新的CRUSADE出血评分系统出台，您对此的看法是什么？
　　Prof Gillebert: It is a very important score. It is also a very simple score. It requires the entry of variables such as gender， age， heart rate and so on and when you have a high CRUSADE score the risk of bleeding can be excessive. So this a trigger for refraining from too invasive or too aggressive anticoagulant treatments in some patients and also an indication to give proton pump inhibitors (PPIs) including omeprazole to patients who are at higher risk. However， omeprazole cannot be given together with clopidogrel. The guidelines tell you formally that if the bleeding risk is higher， you have to protect the patient with proton pump inhibitors.
　　Gillebert：这是一个非常重要而又简单明了的评分系统，该系统要求输入如性别、年龄、心率等变量，得出较高的CRUSADE分数代表了高出血风险，进一步提示需避免一些过度或过激的抗凝治疗，以及在高危患者中应用质子泵抑制剂（PPIs），需注意奥美拉唑不能与氯吡格雷合用。指南正式提出在高出血风险患者中建议使用PPI。
　　International Circulation: In what ways is the CRUSADE Bleeding Score more advantageous than what the guidelines recommended previously?
　　《国际循环》：从哪些方面可以看出CRUSADE出血评分比指南以往的建议更有利？
　　Prof Gillebert: We actually didn’t use a bleeding score previously， but looked at the number of ischemic events saved and then you can see that at a certain point the direct inhibitor becomes very potent and you reach a limit. You reach a limit such that if you increase treatment you have more bleeding and you don’t have less ischemic events so in these circumstances you have to be very careful not to increase the number of bleeding events especially cerebrovascular bleeding and strokes.
　　Gillebert：事实上之前并没有应用出血评分系统，但可以看到缺血性事件的数量在某一个直接抑制点达到极限，因缺血性事件达到极限而增加抗凝治疗将可能导致出血增加，而同时缺血事件也并没有减少，所以在这种情况下，必须非常小心，不能增加出血事件尤其是脑出血和中风的患者。
　　International Circulation: There are also two new kinds of medical treatment， ticagrelor and prasugrel.
　　《国际循环》：您对两种新药怎么看？替卡格雷和普拉格雷。
　　Prof Gillebert: In non-STEMI there is also a big shift in the way we tackle platelet function. In the past， we did so firstly with aspirin， then clopidogrel and thirdly glycoprotein IIb/IIIa inhibitors and sometimes all three were used in combination with a loading of the IIb/IIIa upfront in the coronary care unit distant from catheterization. This led to too many bleeds. Now the cornerstone of therapy for non-STEMI is DAPT (double antiplatelet therapy). Double antiplatelet therapy is firstly aspirin and secondly an inhibitor of the ADP receptor which can be clopidogrel or the newer and safer prasugrel and ticagrelor. These are antiplatelet drugs that are similar to clopidogrel but both have the tremendous advantage that the onset of action is much faster than clopidogrel. The onset of action is within thirty minutes. The second advantage is that clopidogrel has to be transformed into its active form and this can be impeded by simultaneous medication with the statin atorvastatin (Lipitor) and omeprazole. In addition， 5% of the patient population has an allele of a certain metabolizing gene and this allele prevents the rapid transformation of clopidogrel. Because of these reasons， we moved to prasugrel (which still needs to be transformed) and to ticagrelor. Prasugrel has only been investigated in the setting of interventions while ticagrelor is the best drug in the setting of non-STEMI at high risk.
　　Gillebert教授：NSTEMI患者中解决血小板功能的方式有着重大转变。在过去，首先是用阿司匹林，随后是氯吡格雷，接下来是糖蛋白IIb / IIIa受体拮抗剂，有时在冠心病监护病房（CCU）的患者行导管介入治疗前给予大剂量的糖蛋白IIb / IIIa受体抑制剂基础上三药联合使用，但这同时导致出血事件增加。目前NSTEMI患者治疗的基石是DAPT（双联抗血小板治疗），DAPT是阿司匹林和ADP受体抑制剂联合使用，ADP受体抑制剂可以为氯吡格雷或更新、更安全的普拉格雷、替卡格雷，它们的抗血小板作用与氯吡格雷相似，但具有巨大的优势：首先，起效时间在30分钟内，远远快于氯吡格雷；第二，氯吡格雷已被转化为活性形式，它与他汀类药物如阿托伐他汀（立普妥）、奥美拉唑同时使用时相互阻碍；此外，有5％的患者存在某些特定的代谢基因，阻碍了氯吡格雷的快速转型。由于这些原因，普拉格雷（需要进行转型）和替卡格雷或将替代氯吡格雷，其中普拉格雷一般仅用于支架植入术后，而替卡格雷更适合用于高风险的NSTEMI患者。

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