International Circulation: Gene polymorphism influencing DAPT efficacy is a research hotspot. How do we integrate genetic and phenotype information to improve patients outcomes? In order to increase the benefit of patients is routine genetic test necessary?

　　Dr. Collet: Gene polymorphism is a very interesting way and it is helpful because genetic volume carriage does not change over time so it is there over time. It is a very good predictor to clopidogrel resistance and also to clinical outcome. If you are systematically genotyping your patients， you may avoid stent thrombosis for 14 per 10000 patients which is the same benefit you might expect from a secondary level prevention drug like statins.

　　We now need randomized studies looking at the clinical benefits of such strategies.

　　Genetic polymorphism does not address bleeding and this is an issue. You may choose more potent drugs， which may be related to more bleeding. We need to have an algorithm that looks at both sides of the story， ischemic events and bleeding.

　　International Circulation:  2011 ESC guidelines recommend prasugrel or ticagrelor as first-line antiplatelet therapy， level indications， does this mean prasugrel or ticagrelor will be a comprehensive alternative to clopidogrel， may prasugrel or ticagrelor be the mainstream in coronary heart disease?

　　Dr. Collet: ESC guidelines are reasonable because they are very open. They recommend the new drugs for the vast majority of high-risk patients， but still clopidogrel is an option 1A， which means that in countries where these new drugs are unavailable clopidogrel is still a very good option. The recommendations are quite fair and are representative of all kinds of practice over Europe and there are many countries with financial constraints especially in light of the crisis where the new drugs are not available. Clopidogrel is still a grade A recommendation which is fair. Now I think that besides ESC recommendations， you have NICE guidelines which are good because they implement evidence based medicine with economic constraints and I think that is probably the best way to go.

　　《国际循环》：基因多态性影响双联抗血小板治疗疗效是一个研究热点。我们应当如何把基因型和表型信息融合起来，以改善患者的临床转归？为了增加患者的获益，常规开展遗传学检测是否有必要？

　　Collet教授：基因多态性是一个非常有意思的领域，基因多态性是有帮助的，因为遗传学情况不会随时间而变化。基因多态性是氯吡格雷抵抗和临床转归的一个非常好的预测因素。如果我们系统地检查患者基因型，在1000例患者可以避免14例患者发生支架血栓，此种获益等同于应用他汀等药物进行二级预防预期的获益。

　　我们当前需要随机研究去观察这一策略的临床益处。基因多态性并不会提示出血风险，这是个问题。你选择了更强的抗血小板药物，可能会增加出血风险。我们需要看待这件事情的两个方面，即缺血和出血事件。

　　《国际循环》：2011年的ESC指南推荐普拉格雷或替卡格雷作为一线抗血小板治疗，这是否意味着普拉格雷或替卡格雷可以全面替代氯吡格雷，普拉格雷和替卡格雷是否会成为冠心病治疗的主要抗血小板药物？

　　Collet教授：ESC指南更为合理，因为该指南更为开放。指南推荐对于绝大多数高危患者使用新型抗血小板药物，但是对氯吡格雷的推荐级别仍然是ⅠA类，这意味着在没有替卡格雷或普拉格雷的国家，氯吡格雷仍是一个非常好的选择。ESC指南的推荐是相当合理的，能够代表整个欧洲临床实践的方方面面，很多国家有报销的限制，在经济危机情况下尤其如此，此时没有新药。对氯吡格雷仍然做出了A级的临床推荐，这是合理的。现在，我认为除了ESC指南之外，NICE指南也不错，因为NICE指南推行的是循证医学，但是有报销的限制，我认为这可能是最佳的方法。