The use of platelet aggregation inhibitors in the perioperative period

Every year 16 million operations are performed in Germany. Many patients take platelet aggregation inhibitors as a primary or secondary prevention to reduce the risk of cardiovascular events. Especially during the perioperative period, this risk reduction is relevant due to an increased risk for cardiac events (in approximately 6.2% of operations). As a result of a presumed increased risk of bleeding, platelet aggregation inhibitors are often paused perioperatively. Thus, doctors must decide on a risk-adapted basis whether the medication can be continued perioperatively and, if so, with what risks. If acetylsalicylic acid (ASA) treatment is solely used as primary prevention it can be paused during the perioperative period, whereas ASA treatment for secondary prevention should only be paused for operations within narrow confines. When pausing ASA, a sufficient time interval should be maintained before the operation. Furthermore, the ASA withdrawal syndrome with an increased predisposition for clotting is an important phenomenon to be considered. Additionally, the perioperative handling of dual platelet aggregation inhibition needed after coronary stent implantation should be addressed. Due to an increased risk for in-stent thrombosis, dual platelet aggregation inhibition is only reluctantly paused. Emergency surgery must, if not otherwise possible, be carried out even if the dual platelet aggregation inhibition is not paused; however, if the risk for intraoperative bleeding is too high and the risk of an in-stent thrombosis is lower in comparison, P2Y(12) inhibitors (e.g. clopidogrel) should be paused and the operation carried out solely with ASA therapy.