Prof.  Judith S.  Hochman: So we need to address the question  in different components. When somebody presents with acute MI， the earlier the infarct artery is  opened， the better. Time is of the essence. For the people who come late ， after 12 hours following onset of the total coronary occlusion，   the decision to reperfuse depends on clinical stability. Those who aren’t stable， either hemo-dynamically- inshock or heartfailure， or ongoing chest pain，   should have their artery opened-- they should have angioplasty. We showed many years ago in the SHOCK trial， which means the patients were admitted to cardiology with shock， the benefits from angioplasty were very broad. We included these patients up to 48 hours after the MI. We had another occluded artery trial-OAT trial. Patients who have survived for the first 24 hours after MI onset， and were stable withno ongoing chest pain， no severe ischemia， no severe heart failure were eligible forthe trial. Enrolled patients were assigned to the angioplasty or no angioplasty with stent group and all patient received optimal medical therapy . And angioplasty has no benefits. So if you have a patient who presents late after MI onset who is stable， pain free， no hemodynamic complications， and there is no evidence of severe ischemia or heart failure， then they don’t need that open artery at all. You just need optimal medical therapy-aspirin， beta blockers and ACEI， statins and life style modifications etc to reduce the risk. In contast， unstable patients， such as those with cardiogenic shock benefit from revascularization even days after MI onset.

Judith S  Hochman教授：我想这一问题应该分不同阶段来解读，不过要记住一点，越早开通血管越好。如果有病人以急性心肌梗死表现入院，越早开通血管越好。对于就医较晚的患者，比如有些患者病情不稳，就医较晚，出现血流动力学不稳定、心衰或胸痛，即使在第一个12、36或48小时内，这些情况出现，无论是否稳定，都应该接受血管成形术。在多年前的SHOCK试验中，也即所有的病人入院时都出现休克，该试验后证明病人可以从血管成形术中获取广泛收益。我们也纳入了心肌梗死后48小时的病人。在ODD试验中，病人已经度过第一个24小时，情况平稳，无胸痛、无严重却学、无心衰，即被纳入试验，随机分配到血管成形组及非手术组。血管成形组病人并无获益。如果你有一个病人就医较晚，但是病情平稳，无胸痛，无血流动力学不稳定，且没有证据表明严重缺血，则这个病人即不需要接受手术。只需要给予恰当的内科治疗，β受体阻滞剂、ACEI、降脂药物以及生活方式改变以降低风险。

2. <International Circulation>: Aspirin is recommended for all patients with ST-segment elevation myocardial infarction (STEMI). Clopidogrel also should be used in all patients with STEMI; however， the recommended dosages for percutaneous coronary intervention (PCI) and fibrinolysis are not the same.How would we manage anticoagulants and antiplatelet therapy in patients with STEMI?

《国际循环》：所有ST段抬高心肌梗死患者建议使用阿司匹林，氯吡格雷也应该在上述患者使用。然而，在PCI治疗和溶栓治疗STEMI患者时所使用的药物剂量是不同的。在治疗这类患者时，我们怎样正确使用这两种药物呢？

Prof  Judith S  Hochman:Clopidogrel is now recommended in addition to aspirin in the new guidelines for all the STEMI patients， but the dose is different， if you have primary angioplasty， it is 600mg， if you have fibrinolysis， and the age is lesser than 75 years old， your dose should be lowered to 300mg， If you are older than 75， it’s unclear， we don’t have any clinical trial， and we don’t have any safety data on loading doses. So we just have the 75 mg daily dose for the right dose， but we don’t know about loading doses. In general if they are not at increased bleeding risk many physicians use a 300 mg loading dose. It is very important to make sure the dose of heparin is weight adjusted and not too high to lower the bleeding risk I think that we need the clopidogrel in theemergency department and there should be a standard order form and guideline; if the patient is going to cathlab  to have an angioplasty， then look at the list， then decide clopidogrel will be 600mg.When we have medications that are used in different doses for different patients，   you need to have guidance for physicians on the drug selection and doses.In the U.S. we use standard order formsto assure the patients who need clopidogrel and other medications as treatment can receive the right drug and doses.
氯吡格雷已在最新的指南中列出并建议向所有稳定患者应用，但是剂量有所不同，如果进行一期血管成形术，则为600mg，如果行纤溶治疗，且年龄小于75岁，剂量应降为300mg。如果年龄大于75岁，目前尚不是十分清楚，我们还没有安全性数据。可能75mg较为合适，但是目前尚不是非常确定。我认为我们应将氯吡格雷放于急诊室，而且应该制定一套标准或者指南，如果病人进入导管室行血管成形术，只需要看一下列表，就能决定氯吡格雷的剂量为300mg，所以我想药物对不同的病人应该给予不同剂量。应该向内科医生推荐指南，在美国我们有这样的规定，指南可严格限制医嘱中的药物剂量，应采用推荐剂量。我想这保证了需要氯吡格雷治疗的病人能够接受正确的用量。

3.<International Circulation>: What should we do for a patient with ST-Segment elevation myocardial infarction and upper gastrointestinal bleeding? Would you like to do emergency PCI?

《国际循环》：对于一个急性ST段抬高性心梗合并上消化道出血的患者，应该采取什么样的治疗策略？能够进行急诊PCI？

Prof  Judith S  Hochman: Everything we do in medicine is weighing the benefits and risks. If there is small bleeding， medically stable， hemo-dynamically stable， may be only positive occult stool， I would   go ahead and do angioplasty and use gastric protection agents like a proton pump inhibitor.. If somebody is actively bleeding， they are vomiting blood or more severe， then the question is how large the infarct or risk region?   If you’re having a large anterior wall MI， or an MI complicated byheart failure， you would choose primary angioplasty as it is certainly much better than fibrinolysis or no reperfusion. Plain old balloon angioplasty without a stent is probably preferred to minimize the need for antiplatelet agents and anticoagulants. Intravenous proton pump inhibitors should be administered and endospcopy then performed. Everything we do is weighing the benefit/risk ratio， if it is small infarcted， inferior wall MI and actively GI bleeding or vomiting blood， I will treat probably them with medical therapy alone， no primary angioplasty， no fibrinolysis， so you will always have to weigh how much bleeding， are their bleedings stable or unstable， how high risk is the MI- what is the mortality without reperfusion therapy and what is the expected mortality reduction with reperfusion based on the time from symptom onset to treatment?  We will try to answer it. The primary angioplasty is less dangerous than fibrinolysis to somebo