<International Circulation>:  We need to know the right drug， right combination and also the right time in antithrombotic therapy in ACS. What are your thoughts on triple antithrombotic therapy and when do we need it?

    Prof. Lip: We would require the use of triple antithrombotic therapy in patients essentially where they would need background anti-coagulation therapy for one reason or another. The most common situation would be atrial fibrillation at high risk of stroke. As mentioned previously， anti-coagulation works well in this context. However， if they presented in acute coronary syndrome or they have a stent， there is fairly good evidence that warfarin is inadequate in those settings because the type of thrombus in acute coronary syndrome or if it forms in a stent thrombosis， it is a platelet-rich clot or in other words， “white” clot， so antiplatelet therapy works well. Combination antiplatelet therapy with either aspirin plus a thienopyridine such as ticlopidine or more recently clopidogrel and one of the newer agents such as prasugrel combination antiplatelet therapy is the way to treat such patients. In the patients who require anti-coagulation because of another reason， the aim is to try to balance stroke prevention with recurrent cardiac ischemia or stent thrombosis against the risk of bleeding. What sort of patients will require triple antiplatelet therapy at least in the initial period after an acute coronary syndrome or a percutaneous intervention or stent? It will be the patients who are high enough thrombo-embolic risk to require anticoagulation， for example high risk patients with atrial fibrillation at high risk of stroke， those who have prost