Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

Background: The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). Methods: Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. Results: A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031. Conclusions: OBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI

Change that Respects Business Expertise: Stories as Prompts for a Conversation about Organisation Security

Leaders of organisations must make investment decisions relating to the security of their organisation. This often happens through consultation with a security specialist. Consultations may be regarded as conversations taking place in a trading zone between the two domains. We propose that supporting the trading zone is a route to sustainable, workable security change improvements. Prompts for such improvements are already in place, in the security stories that reach business leaders through news media, or anecdotes from trusted peers. However, a shift in perspective is needed to view these stories and anecdotes as prompts for individual decision makers to enter into the trading zone with security specialists. We illustrate how to facilitate this shift by recasting security ontology tools, previously centred around security-specific expertise, as a support device to enrich conversations between business expertise and security advice toward finding workable security choices. We frame our proposal within a broader view of community transformation, exploring the important principle of identifying practical opportunities to inform discussions about security solutions that are appropriate in the business context. Community-level discussions have potential to lead to more lasting, effective improvements than those instigated by one-way interventions from security specialists. We extend the view, applying the paradigm to articulate the importance of two-way conversations between business peers and security specialists.Organisation and Governanc