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While there have been substantial advances in the use of anti-platelet therapies (APTs) in many conditions such as acute coronary syndrome and coronary interventions,1 the appropriate management of APT for patients undergoing non-cardiac surgery continues to remain a topic of discussion.With asmanyas one-fifth of the patients requiring noncardiac surgery within 1 year after coronary stent implantation,2weighing the riskof haemorrhagic complications in the peri-operative period against the possible ischaemic complications, especially stent thrombosis after recent coronary stenting, is a critical decision for every physician involved. Our currentguidelinesgenerally donot recommend theuse of aspirin peri-operatively.3 The Perioperative Ischemic Evaluation 2 trial randomized over 10,000 patients undergoing non-cardiac surgery to aspirin or placebo before surgery. Rates ofmyocardial infarction and deathwere not reduced by use of aspirin 30 days after surgery, whereas major bleeding did increase.4However, considering only 23% of included patients had known coronary artery disease and all patients undergoing carotid endarterectomy were excluded in the trial, it is possible that patients with low peri-operative bleeding risk and high thromboembolic risk, might benefit from aspirin peri-operatively.3 For patients on dual APT (DAPT) undergoing surgery, it is indeedrecommended toperformsurgerywithout discontinuation of aspirin or P2Y12 inhibition if surgery is performed within 1 month after bare-metal stent implantation and 3 months after drug-eluting stent implantation. If surgery is planned outside these timeframes, current guidelines uphold a universal approach of 5 days withdrawal for clopidogrel and ticagrelor, and 7 days for prasugrel prior to surgery and to continue aspirin.3,5 For all patients who are at especially high risk for stent thrombosis, bridging strategies can be contemplated.3,5 As it is widely known that individual responses to clopidogrel and platelet function recovery after clopidogrel withdrawal highly vary,6,7 determining the right timing for surgery might be more appropriate with platelet function testing (PFT) that monitors the response of the patient to the withdrawal of clopidogrel exclusively. In patients undergoing coronary revascularization surgery by coronary artery bypass grafting (CABG), platelet function monitoring is recommended in current guidelines as anoption for timing of surgery instead of the standard withdrawal period of 5 days for clopidogrel.5,8 Assessment of platelet function predicts peri-operative bleeding in patients undergoing cardiac surgery, as well as reduces blood transfusions and hence might decrease transfusion-related complications, although clinical trials in various settings do not report a beneficial effect on post-operative mortality and surgical reexploration rates.9–12 In a prospective, single-centre nonrandomized study, pre-operative PFT by thrombelastography in order to determine the timing of CABG in patients treated withclopidogrel,wasassociatedwithnoexcessbleedingwhen compared to clopidogrel—naive patients, and let to pre-operative waiting time reduction of 50% as compared to what is recommended in the current guidelines.13However, although PFT is endorsed as a useful tool to determine appropriate timingofcardiac surgery,more research in thisfield isurgently needed as there is still much uncertainty about the optimal tests and cut-off values for determining the timing of surgery. In the previous issue of Thrombosis and Haemostasis, Mahla et al present the BIANCA study, a prospective study that examines the association between platelet reactivity to adenosine diphosphate (ADP) and bleeding complications in non-cardiac surgery.14 In cardiac surgery, mechanisms of bleeding involve a complex interaction involving among others, hypothermia, excessive fibrinolysis, haemodilution from pump priming and, most importantly, platelet function defects due to cardiopulmonary bypass. While this effect might be absent in non-cardiac surgery, still the assessment of pre-operative platelet functionmay optimize the timing of non-cardiac surgery, and therewith minimize both bleeding and thrombotic complications, as Mahla et al suggest in their article.14

Platelet Inhibition and Bleeding Risks in Patients Undergoing Non-Cardiac Surgery