Aspirin, clopidogrel, and the surgeon.

The rising use of antiplatelet therapy for primary prevention and secondary prevention of cardiovascular and cerebrovascular events poses a dilemma for physicians in the perioperative period. The proven benefits of aspirin in preventing further thrombotic events in patients with prior ACS or stroke make it difficult to withdraw this therapy. The risk of hypercoagulability associated with surgery is also independent of antiplatelet withdrawal, but adds to the rebound effect of platelet responsiveness. Therefore, aspirin should be continued whenever feasible. Similarly, the use of thienopyridines such as clopidogrel, especially for the prevention of stent thrombosis, should be maintained for at least the recommended time frame, if not longer. It is recognized that maintaining antiplatelet therapy is also not without risk, as bleeding complications have been well documented. Unfortunately, current perioperative guidelines do not often provide a simple solution for management. Therefore, the risk of bleeding has to be weighed against the risk of thrombosis, and decisions should be made with all providers caring for the patient on an individual basis.