The growing incidence of cardiovascular diseases leads to an increase in patients who require treatment with antiplatelet drugs. About 5% of patients who underwent a percutaneous coronary intervention will have to undergo surgery within the first year. In these patients the problem evolves how to handle the antiplatelet therapy in the perioperative period. A continuation of these drugs in order to reduce cardiovascular events is associated with increased perioperative bleeding. Withdrawing antiplatelet agents in order to reduce surgical hemorrhage leads to a significant increase of cardiovascular morbidity and mortality, especially in patients who have been treated with implantation of drug eluting stents. This review balances the specific risks of either approach and offers an algorithm how to manage patients in need for antiplatelet therapy in the setting of (un-)planned surgery.