Antiplatelet therapy and coronary stents in perioperative medicine - the two sides of the coin

New trends in interventional cardiology, e.g. the increasing practice of coronary intervention with stent implantation and the prolonged use of dual antiplatelet therapy - usually a combination of clopidogrel and aspirin - has also increased the number of patients presenting for non-cardiac surgery. The two most commonly used stent types, bare-metal stents (BMSs) and drug-eluting stents (DESs), mandate different lengths of dual antiplatelet drug therapy to avoid stent thrombosis. Perioperative caregivers face a knife-edge dilemma between perioperative stent thrombosis, due to preoperative discontinuation of antiplatelet drugs, or surgical bleeding, by continuation of therapy. Pre- and intraoperatively, the risk factors for thrombosis have to be balanced against the risk factors for surgical bleeding. As long as prospective trials are not available, the recommendations and guidelines of task forces and experts are based on retrospective studies and case reports. The perioperative management, decision trees and the importance of close interdisciplinary collaboration between cardiologists, surgeons and anaesthetists will be described.