[Comment about patients with dual antiplatelet therapy].

We have read with great interest the article by Dr. Bassas et al regarding the use of antiplatelet and anticoagulant treatment in dermatological surgery. We would like to congratulate the authors on their excellent and exhaustive review.1 We agree with their conclusion: there is no scientific evidence supporting the withdrawal of antiplatelet therapy in dermatological surgery settings, and it is preferable to bear with the inconvenience implied by maintenance rather than assume the serious thrombotic risk implied by withdrawal.2,3 Nonetheless, there are no agreed guidelines and the literature is extensive and contradictory. Furthermore, old habits die hard, and therapy often continues to be suspended 7 to 10 days before surgery. In an American study published in 2007, in which anonymous questionnaires surveying routine practice were sent to 720 dermatological surgeons (with a 38% response rate), primary and secondary antiplatelet therapy was suspended in 87% and 37% of cases, respectively.4 Comparison of these results with those obtained in a similar study carried out in 2002 clearly appears to indicate that there is an increasing tendency to withdraw therapy.5 When deciding whether or not to suspend antiplatelet therapy, it is important to assess both the risk of hemorrhage— which is considered to be low for dermatological surgery, although it depends on the part of the body and the type of surgery—and the risk of thrombosis. It is also important to be aware of the indication for the therapy and to distinguish between patients receiving antiplatelet therapy for primary prevention (prophylaxis for patients at high risk for reasons of age, blood pressure, smoking, kidney failure, dyslipidemia, diabetes mellitus, or obesity) or secondary prevention (after an ischemic or thromboembolic episode).2,4 We wish to draw attention to the subgroup of patients for which it is now considered vital to maintain antiplatelet therapy, namely, patients receiving dual antiplatelet therapy with acetylsalicylic acid and clopidogrel following coronary revascularization surgery.6,7 Cardiological and other medical associations recommend maintaining antiplatelet therapy for at least a year after the insertion of an antiproliferative drug-eluting stent for paclitaxel or sirolimus, given that premature withdrawal may lead to obstruction of the stent with disastrous consequences. In patients receiving dual antiplatelet therapy, the relative risk of bleeding is estimated to increase by 50%. For this reason, some authors recommend postponing the surgery, if at all possible, until treatment with clopidogrel is concluded.5,6,7 In cases where surgery cannot be postponed, it is recommended to consult the cardiology and anesthesiology departments in order to agree on management.