This paper describes the management of three patients for elective surgery with drug-eluting stents in the coronary circulation. The risks posed at the time of surgery by such patients include acute coronary syndromes, as a result of stent thrombosis, after cessation of anti-platelet therapy and excessive bleeding from continued anti-platelet therapy. We describe a regime for the management of such patients that successfully avoided these risks in three patients with paclitaxel drug-eluting stents requiring elective non-cardiac surgery.

Drug-eluting stents are a recommended treatment for lesions in the coronary arteries. Stent insertion requires the patient remain on antiplatelet medication for a minimum of six months after insertion. A serious consequence of ceasing antiplatelet medication is late stent thrombosis leading to myocardial infarction in the territory of the drug-eluting stent. Continuing antiplatelet medication can lead to excessive bleeding at the time of surgery. Understanding the risk of complications attributable to bleeding or myocardial ischaemia will help in defining the optimal management of these patients at the time of noncardiac surgery. This study is a retrospective database analysis and case note review of all patients with drug-eluting stents presenting for noncardiac surgical procedures over a three-year period in one centre. Twenty-four patients with drug-eluting stents inserted presented for 43 noncardiac surgical procedures. Severe bleeding problems were encountered in one case. Three of 15 patients (20%) who ceased clopidogrel prior to surgery without alternative anti-thrombotic prophylaxis suffered myocardial infarction due to stent thrombosis. Four patients who received alternative anti-thrombotic prophylaxis did not suffer complications. All 19 patients who ceased clopidogrel remained on aspirin prior to surgery. Patients treated with drug-eluting stents for coronary artery stenosis represent a challenging group of patients for subsequent perioperative management. The risk of myocardial infarction when clopidogrel is stopped prior to surgery is 20%, if alternative anti-thrombotic prophylaxis is not used. This risk persists beyond one year after insertion of drug-eluting stents. Some treatments appear to be effective in reducing the risk of myocardial infarction.

Rates of caesarean section are a cause of concern worldwide, although the problems vary according to the setting. In many poor countries, mostly in Africa, where average rates are 2%, caesarean section is underused because of lack of facilities and trained personnel. In other developing countries, such as ones in Latin America and eastern Asia, incidence is 30% of all births or higher, even though large sections of the population lack access to basic obstetric care, while in developed countries it has steadily risen to about 20-25%.1 Despite such big differences between countries, the modifiable causes of rising caesarean section rates and what to do about them are unclear.In this week's BMJ, a randomised controlled trial by Montgomery and colleagues looks at the effect of two computer based decision aids compared with usual care in pregnant women who have had a previous caesarean section.2 One aid provided structured information about possible outcomes and their probabilities associated with different modes of delivery and left women's preferences implicit; the other was a decision analysis model that required women to define their preferences, while information about probabilities was concealed.Importantly, one of the outcomes measured in the trial was the actual birth method, which usefully separates how choices are experienced from the option chosen. The trial found that both aids significantly improved the subjective experience of women about their choices compared with usual care. However, rates of caesarean delivery were similar in the information group, and lower in the decision analysis group compared with usual care.Unlinking the experience of decision making from its outcome brings a refreshing perspective to the problem of overuse of caesarean section. In light of these authors' findings, it is tempting to conclude that the rise in caesarean rates is due to delivery being seen as purely a medical problem, and the solution being guidelines and recommendations. In 1985, representatives of a study group convened by the World Health Organization wrote, "there is no justification for any region to have caesarean section rates higher than 10-15%."3 At the time, such levels were considered high but acceptable in developed countries. However, now that caesarean rates in many countries exceed 20%, the recommendation has been dramatically overtaken by events. Notably, rates continue to rise despite evidence showing that caesarean delivery may increase the risk of maternal death.1 4 5 Surprisingly little research exists on determinants of caesarean section, at either the aggregate or the individual level.6 7 The few randomised trials that have been published found no effect of decision aids on caesarean section rates.8 9 This is despite evidence in other areas of medical care showing that decision aids such as pamphlets and videos can improve people's knowledge of the options, create realistic expectations of their benefits and harms, improve decision making, and increase participation in the process.10 Against...