<International Circulation>:Currently there are some new adjunctive drugs such as prasugrel that support PCI for patients with STEMI， according to the updated ACC/AHA 2009 guidelines.  What is your opinion about prasugrel and what are the advantages or disadvantages of this drug?

    Roxana Mehran: I actually have a lot of experience with that particular study and the results.  Obviously， the sub-study in the STEMI population looks fantastic from the TRITON-TIMI 38 study but there needs to be full knowledge of the fact that particular drug was never studied in STEMI patients a priori.  It was a pre-specified sub-analysis so you have to look at it; you can’t ignore it.  However， I think we need to have long term and well powered studies to learn the safety and efficacy of prasugrel in the STEMI patient population.  What concerns me about the STEMI patients is that we are so fast in treating them， if you give them a dose of prasugrel without knowing their history of bleeding diathesis， etcetera， that we may get into trouble in just applying it to all STEMI patients. There has to be a gatekeeper that takes care of the important risks that prasugrel has in the patients who are prone to bleeding.  And that does need to be eliminated.  Because if you do that to all STEMI patients across the board， then we are going to have a lot of patients dying of inter-cranial bleeds and I think that is important to make that distinction up front in the patients with STEMI.