Kasivisvanathan and colleagues open the door a little further to tailored antiplatelet therapy, showing good prediction of bleeding, transfusions, severe morbidity and the need for redo surgery.

In a prospective case-control study of 368 patients undergoing mixed non-cardiac surgery, 182 patients who did not stop clopidogrel treatment in due time were identified on the day of surgery. ADP platelet receptor inhibition, i.e. the degree of platelet inhibition induced by clopidogrel, was evaluated by thromboelastography platelet mapping, and the threshold for high versus low inhibition was set at 30%.

Compared with case-matched controles, patients with a high platelet inhibition had an increased risk of intra- and postoperative transfusions, need for redo surgery and severe morbidity. The relative risk of receiving 2 or more intraoperative packed red blood cell transfusions was 3.75 . A further important finding was the poor correlation between the duration of clopidogrel interruption and platelet inhibition, which is consistent with the known interindividual variability observed with clopidogrel treatment.

These results support the paradigm of tailored antiplatelet therapy, not only on initiation but also on discontinuation. In the era of goal-directed and personalised medicine, one size does not fit all.

– Jakob Stensballe

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