<International Circulation>: Dr. Conti， I’d like to thank you for joining International Circulation at the ACC 2014 sessions. Now， first of all it’s an honor of having you here with us today. We’d like to talk a little bit about guidelines. We’ve seen a lot of new guidelines coming out and， this year we saw the release of some AHA/ACC joint guidelines. I’d like to ask you about some European guidelines， actually. In the 2013， ESC guidelines for the management of stable coronary artery disease， these were an update on their 2006 guidelines for the management of stable angina pectoris. But the newer guidelines have broader coverage. And I know， as an American physician， you would probably look at the American guidelines， but there’s also a comparison across different societies. Can you give us your viewpoint on those particular guidelines?

　　Charles Richard Conti: Well， first of all， thanks for interviewing me， and I enjoy doing this， and I’m looking forward to going back to China. One of the things that you have to learn about guidelines is that -- guidelines are the results of clinical trials. And clinical trials apply to patients who are entered into the clinical trials. They have nothing to do with patients who don’t meet entry criteria. So， guidelines are guidelines. They’re not rigid ways to practice cardiology. They’re suggestions. So that’s the way I look at them.

　　Now， the Europeans seem to be at warp speed relating to the US change of our guidelines. They do it fairly quickly. They’re very efficient -- not only in the stable angina， but in other areas as well. I don’t think there is much difference with the European guidelines related to stable angina. We all are very vigorous and aggressive in managing these patients， whether it is with interventional work， some other techniques or with drugs. I think they have a few drugs that we do not. For example， Ivabradine is one that they use for stable angina， or for heart failure for that matter. We should have Ivabradine， but our FDA has not approved it yet. I don’t see much in the way of clashes， you know， I don’t think they are saying we don’t do it right， and they do it right.

　　《国际循环》：Conti博士，非常感谢您能在ACC 2014现场接受《国际循环》的采访。首先，非常荣幸今天能在这里采访您。我们想请您谈一下有关指南的问题。现在很多新指南陆续发布，包括AHA/ACC联合发布了一些指南；我们也想请您谈谈谈欧洲指南。2013年ESC发布了稳定性冠心病管理指南，可看作2006年稳定性心绞痛指南的更新，但新指南覆盖范围更广。作为美国医生，您虽然可能更多关注美国指南，但也会对不同学会制订的指南进行比较和分析。您对这些特定指南有何看法？

　　Charles Richard Conti博士：首先，非常感谢您的采访，我很乐意接受采访，也期待能再有机会去中国。我们需要知道，临床指南实际上是根据临床试验结果制订，而临床试验结果只适用于那些被入选至其中的患者，对不符合试验入选标准的患者来说则没有意义。因此，我认为指南只是一种建议，不能被僵化地用于临床实践。

　　现在，与美国指南更新速度相比，欧洲指南更新更快。欧洲在不断快速有效更新其稳定性心绞痛及其他领域的指南。但我并不认为我们的指南与欧洲稳定性心绞痛指南有太大差别。我们都强调要采用介入治疗、其他技术或药物对这些患者进行积极有效的管理。只是欧洲指南推荐了几种我们不推荐应用的药物。例如，欧洲指南推荐伊伐布雷定用于稳定性心绞痛或心力衰竭的治疗，当然我们应该也需要这种药物，但至今尚未被美国FDA批准上市。我认为，美国指南与欧洲指南之间并没有什么冲突，不能说他们做得对，或我们做得不对。

　　<International Circulation>: As you mentioned， they seem to have been able to develop their guidelines quicker. Do you think there has been mentioned too much of evidence -- saying， everything in the American guidelines has to be evidence-based? We’ve seen the hypertension guidelines which were delayed for many years， and we’ve finally seen them starting to come out. As a result， do you think it leaves physicians with kind of advices?

　　Charles Richard Conti: You’re asking a very important question. Let me address this business of hypertension. When I was a medical student in the 50s， normal blood pressure was 100 plus your age. So if you were 79 or 80， it was 180， which is non-sense. That’s just not right. If you were 20 years old， that would be 120， which is just fine. So what happened with the American guidelines for hypertension， as I interpret them， it seems to be that they have raised the level a little bit. It used to be 140 or low. Now， for an older patient， who may have chronic disease， or cerebral disease， they say 150 might be ok. So that’s the way I look at those things.

　　《国际循环》：正如您刚才所说，欧洲指南更新相对较快。您是否认为美国指南过多地强调了证据基础？我们知道美国的高血压指南就延迟发布了很多年。因此，您认为其对临床医生有哪些建议?

　　Charles Richard Conti博士：这个问题非常重要。我来谈一下高血压问题。上世纪50年代，当时这么认为，当我还是一名医学生的时候，那时正常血压=100+年龄 mm Hg。因此，如果你79岁或80岁，即使血压达到180 mm Hg，也被视为正常。而如果你仅仅20岁，正常血压应为120 mm Hg。当然，这是不正确的。我对美国高血压指南的理解是，他们只是提高了正常血压上限。过去其推荐上限是140 mm Hg。而现在对可能合并慢性疾病或脑血管疾病的老年患者，指南则强调将其血压控制在150 mm Hg左右也可以。我是这样看待这一问题的。

　　<International Circulation>: In general， has been there such an emphasis on the idea of evidence based that it has delayed guidelines?

　　Charles Richard Conti: Let me address this business of evidence-based. If we look at the level of the evidence in most evidence-based guidelines， the level of evidence is "C"， which stands for consensus opinion. So， if we consider that evidence based， that’s your business. But it’s not a randomized， controlled trial， twice done， in every instance. So， it varies from bit to bit here. I think one has to look at that. Physicians， thoughtful physicians， look at the guidelines as guidelines. Ok， this is not an unreasonable way to do it -- let say， if they’re class Ⅲ， it’s a very good reason not to do it. The evidence-based is a little wishy-washy. It’s not as tight as you might think in every instance.

　　《国际循环》：通常来说，强调循证依据是不是会延迟指南制订？

　　Charles Richard Conti博士：我想谈论一下以基于证据这一问题。大多数循证指南中相关推荐的证据水平为C，属于专家共识性意见。因此，大多数人认为这些推荐是以循证为基础，但实际上其并非根据随机对照试验制订。我认为大家在阅读指南时要关注这个问题。医生，尤其是严谨的医生，应该仅把指南看作指南。这样做是合理的。如果推荐的证据等级仅为Ⅲ级，则我们有理由在临床实践中避免使用。也就是说，目前指南推荐的循证依据并没有我们想像的那般严谨。