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Point-of-Care Guided Strategy for Clopidigrel Suspension in Patients Undergoing Coronary Surgery
No full textIn their recent study Seese and colleagues evaluated the impact of preoperative clopidogrel exposure on outcomes of coronary artery bypass grafting (CABG).1 Patients who received preoperative clopidogrel had higher rates of transfusions, reoperation for bleeding, stroke and prolonged ventilation. Clopidogrel exposure did not affected mortality or hospital readmission.
We read with interest this article that challenges current guidelines suggesting clopidogrel withdrawn at least 5 days before surgery in elective patients needing CABG to reduce bleeding, blood products usage and related complications.2 Shorter periods of 3 days or less could be evaluated in unstable patients to mitigate cardiac risk waiting for platelets function recovery.
Based on the assumption of wide interindividual variability in recovery time after clopidogrel withdrawal and large range of individual responses to clopidogrel,3 our case-control study analysed the possibility to guide the time of preoperative clopidogrel discontinuation using an individualized point-of-care platelet function measurement. Conclusions supported a different, individualized, approach for the optimal time for CABG surgery, especially in patients needing urgent surgery.4 In this study, platelet function daily monitoring provided an objective guideline for a flexible timing of surgery with bleeding reduction and blood products consumption. We identified many patients with unmodified platelet function despite an adequate dosage of clopidogrel (clopidogrel-resistant) and patients who displayed a faster recovery (within 2–3 days) of platelet function after discontinuation of clopidogrel (clopidogrel-poor-responders). In contrast, about 20% of patients had persistent platelet inhibition and required from 6 to 10 days for complete recovery after clopidogrel discontinuation.
We believe that the point-of-care guided preoperative administration/discontinuation of antiplatelet agent could be indicated for an individual approach to patients to reduce both bleeding and adverse events compared with the current practice of unselected timing.
References
1. Seese L, Sultan I, Gleason TG, Navid F, Wang Y, Kilic A. The impact of preoperative clopidogrel on outcomes after coronary artery bypass grafting. Ann Thorac Surg.2019;108:1114-20.
2. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J 2018;39:213-60.
3. Mannacio V, Di Tommaso L, Antignano A, De Amicis V, Vosa C. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of Coronary artery bypass occlusion After off-pump procedures) randomised study. Heart 2012;98:1710–5.
4. Mannacio V, Meier P, Antignano A, Di Tommaso L, De Amicis V, Vosa C. Individualized strategy for clopidogrel suspension in patients undergoing off-pump coronary surgery for acute coronary syndrome: a case–control study. J Thorac Cardiovasc Surg 2014;148:1299–306
Antiplatelet therapy suspension in patients undergoing coronary surgery for acute coronary syndrome: Is point-of-care guided strategy the best choice?
Full text linkPerioperative Management of Clopidogrel: Pay Also Attention to Patients Highly Responders
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Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
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