<International Circulation>: What is your basic feeling of all three drugs in terms of when they should be used?   What their different indications are?  And， which ones work better than others?

   《国际循环》：当提到这三种药物应该用于临床时，您的基本的感觉是什么？它们的适应证是什么，还有，其中哪一种药物更好？
 
    Prof. Wright:  My perspective on these drugs are not official policy of the American College of Cardiology， American Heart Association， or the guideline process.  Clopidogrel has a very strong track record and will soon be generic in the US.  It is an effective drug and works very well.  Prasugrel appeared to work a little better in the TRITON study， with an almost 2% net clinical benefit.  Prasugrel also has an advantage that it is not affected by the CYP-C219 pathway， so the people who have the alleles that make them hyporesponsive to clopidogrel will not have that risk with prasugrel.  Prasugrel was associated with a slightly higher risk of bleeding， so you have to carefully select patients for prasugrel and make sure you don’t use prasugrel in someone who has an elevated bleeding risk.  Ticagrelor was also shown to be superior to clopidogrel in several studies， with the PLATO trial being the biggest study.  I anticipate that ticagrelor， which has a more potent anti-platelet action than either prasugrel or clopidogrel， will gain a significant uptake in the US， without concern or worry about the bleeding risks of prasugrel or the hyporesponsiveness of metabolism of clopidogrel.  What we will be using in a year or two in the US is most likely that most patients will be on clopidogrel.  The second most will be on ticagrelor， while third will be on prasugrel.  All three are effective and all three work well.  I would have no hesitation in using any of them in myself or my patients， but I think that cost will drive the use and with clopidogrel going generic costs triumph everything else.  

    Wright教授:我的关于这些药物的观点并不是美国心脏病学会、美国心脏协会的官方政策，也不是指南的走向。氯吡格雷有一个强大的随访记录并且将很快在全美普遍应用。它是一种有效的药物，疗效很好。TRITON研究显示普拉格雷疗效稍好，有将近20%的净临床获益。普拉格雷还有一个优势，它不受CYP219途径的影响，因此，拥有对氯吡格雷低反应性的等位基因的人服用普拉格雷不会有那种（低反应的）风险。普拉格雷与略高的出血风险相关，因此我们不得不慎重地选择患者来服用普拉格雷，确保那些出血性升高的患者不会应用普拉格雷。替卡格雷在某些研究中也优于氯吡格雷，其中以PLATO试验为最大的试验研究。我预计，替卡格雷因其具有比普拉格雷和氯吡格雷更强有力的抗血小板的作用，将在美国赢得显著的（使用率）的上升。而不必担心普拉格雷或低反应性氯吡格雷代谢的相关出血风险。我们在未来一、两年美国应用的药物极有可能应用最多的药物为氯吡格雷，第二位的为替卡格雷，第三位的为普拉格雷。这三种药物疗效都非常好。我会毫不犹豫地选择以上三种药物中的任何一种以用于我自己或者我的病人。但是我认为费用会驱动药物的应用并且由于氯吡格雷成本较低将赢得最后的胜利。

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