International Circulation: Why do acute coronary syndromes have such a complex landscape? What is the significance of this concept in the management of ACS?

　　Dr Giugliano: There are many complexities to the biology that underlies acute coronary syndromes. Most acute coronary syndromes are due to plaque rupture in a coronary artery. There are other etiologies as well， but let’s focus on that main cause. There are a number of pathophysiological processes that lead to the rupture in the plaque and the downstream consequences， so there is no one simple silver bullet to either prevent an acute coronary syndrome or to treat an acute coronary syndrome event. Amongst the key factors that play into this are risk factors like smoking， diabetes， hypertension and high blood cholesterol， which is why for the prevention of ACS， we need a multifaceted approach which targets all of these risk factors. Once the plaque ruptures， we have quite a bit of activity occurring at the site. There is blood that clots and coagulates; there is the activation of platelets; there is ongoing inflammation; and mechanical obstruction. So the treatment includes relieving the obstruction， administering drugs to block clot formation into thrombin and fibrin， administering antiplatelet therapy， and trying to stabilize the plaque with drugs like statins that reduce cholesterol and also have an anti-inflammatory effect. It is the notion that the biology is complex and that there is no one single therapy that can take care of all of those issues which means we have a number of therapies that are required for both prevention and treatment of ACS.

　　《国际循环》：为何急性冠状动脉综合征（ACS）具有复杂性？这一概念在ACS管理中有何意义？

　　Giugliano教授：急性冠状动脉综合征（ACS）的生物学有许多复杂之处。大部分ACS是冠状动脉斑块破裂所致，还有其他的病因，但我们先关注这个主要原因。导致斑块破裂和下游后果的病理生理过程有很多，因此要预防ACS或治疗ACS事件，没有简单的捷径可走。与此相关的关键因素有吸烟、糖尿病、高血压和高血脂等，这也是为何对于预防ACS而言，我们需要一种针对所有这些危险因素的多方面的方法。一旦斑块破裂，局部会发生很多变化，如血液凝块和凝结、血小板活化、炎症发生以及机械性梗阻。因此治疗包括减轻梗阻、给予药物以阻止凝块形成、给予抗血小板治疗以及尝试用药物来稳定斑块，如采用能降低胆固醇且有抗炎作用的他汀类药物。针对这种复杂的生物学现象，并没有一种单一的治疗方法可以应对所有这些问题，这意味着要预防和治疗ACS，我们需要多种治疗方法。

　　International Circulation: There are still many controversies in STEMI management. What are the main issues in this field?

　　Dr Giugliano: We have made tremendous progress in ST-elevation MI. when I was in training in medical school， the mortality rate from myocardial infarction was around 20-30%. Now， it is well below 10%. Some things are clear， like everybody should be using aspirin and everybody should receive a second antiplatelet (although there is a debate as to what that should be)， everybody should receive an anticoagulant and wherever possible and quickly available， everybody should receive coronary angiography， angioplasty and stenting. Some of the controversies revolve around delays in getting a procedure if it is not available or a distance away. Are there other things that can be done at the time of intervention such as aspiration of the thrombus? Based on my reading of the data and the discussion at the session here， that would not be a routine approach. What are the best types of stents? And what are the optimal treatments after the procedure? What we are seeing is getting patients to the catheterization lab as soon as possible is important. Putting in a more modern stent appears to be advantageous due to lower rates of restenosis and stent thrombosis. Administering at least two antiplatelets afterwards is also recommended along with cholesterol lowering， blood pressure and blood glucose control. There are some things that are still controversial but many of the therapies are now becoming standardized. We will continue to evolve and innovate but I think the major advances have occurred in this field and future advances will be at the margins.

　　《国际循环》：ST段抬高型心肌梗死的管理仍存很多争议。这一领域的主要问题是什么？

　　Giugliano教授：我们在ST段抬高型心肌梗死（STEMI）方面已经取得巨大进步。我在医学院接受培训时，心肌梗死的死亡率约为20%~30％，而现在则<10％。有些事情是明确的，如每例患者都应该尽可能快速地应用阿司匹林、第2种抗血小板药物（尽管在应该是哪种药物上存在争论）以及一种抗凝药物的治疗，且每例患者都应该接受冠状动脉造影、血管成形术和支架置入术。对没有条件或者距离远的情况下介入实施延迟的问题存在一些争议。如在干预时可以实施其他诸如血栓抽吸之类的措施吗？据我了解的数据以及现场辩论环节的讨论，这不会是常规的做法。那么最佳的支架类型是什么？手术后最佳的治疗方法是什么？我们所看到的是，尽快让患者进入导管室至关重要。采用更现代的支架可能是有利的，因为再狭窄率和支架血栓率较低。另外还推荐之后给予至少两种抗血小板药物，伴降低胆固醇的治疗以及控制血压和血糖。有一些问题仍存在争议，但很多疗法正在标准化。我们将继续发展和创新，但我认为在该领域已经发生了主要进展，未来的发展将会是在边缘领域。