Should I continue aspirin (acetylsalicylic acid) and Lovenox (enoxaparin) or stop one before pacemaker placement?

Management of Aspirin and Lovenox Before Pacemaker Placement in a Patient with Aortic Valve Replacement

For a patient with an aortic valve replacement undergoing pacemaker placement, you should discontinue Lovenox (enoxaparin) 24 hours before the procedure while continuing aspirin throughout the perioperative period.

Rationale for Anticoagulation Management

Aspirin Management

• Patients with mechanical heart valves have a high thrombotic risk that outweighs the bleeding concerns associated with pacemaker implantation 1
• The American College of Cardiology/American Heart Association guidelines recommend continuing aspirin throughout the perioperative period for patients with high thrombotic risk, including those with prosthetic heart valves 1, 2
• Aspirin provides essential protection against valve thrombosis, which carries significant morbidity and mortality risk

Lovenox Management

• Lovenox (enoxaparin) should be discontinued at least 24 hours before the pacemaker procedure to minimize bleeding risk 1
• For procedures with moderate bleeding risk like pacemaker implantation, the last dose of LMWH should be administered >12 hours before the procedure 1
• Lovenox can be resumed 24-48 hours after the procedure, depending on hemostasis assessment 1

Specific Recommendations Based on Valve Type

For Mechanical Aortic Valve:

• Continue aspirin (81-325 mg daily) without interruption through the perioperative period 1
• Stop Lovenox 24 hours before the procedure 1
• Resume Lovenox 24-48 hours after the procedure when hemostasis is adequate 1
• If the patient is bridging from warfarin, resume warfarin on the evening of the procedure 1

For Bioprosthetic Aortic Valve:

• Continue aspirin without interruption 1
• If Lovenox is being used for thromboprophylaxis rather than bridging, it can be resumed 24 hours after the procedure if hemostasis is adequate 1

Bleeding Risk Assessment for Pacemaker Implantation

Pacemaker implantation is considered a procedure with moderate bleeding risk, but several factors should be considered:

• Pocket hematoma is the most common bleeding complication (2-5% incidence)
• Continued aspirin therapy increases this risk slightly but is generally well-tolerated
• The risk of valve thrombosis (with potential mortality) outweighs the risk of pocket hematoma (manageable morbidity)

Common Pitfalls to Avoid

• Do not discontinue both anticoagulants simultaneously - this creates excessive thrombotic risk for a patient with a prosthetic valve 1
• Do not restart Lovenox too soon after the procedure - wait at least 24 hours to ensure adequate hemostasis 1
• Do not delay restarting anticoagulation beyond 48-72 hours - this increases thrombotic risk 1
• Do not use NSAIDs for post-procedure pain - they increase bleeding risk when combined with aspirin 1

Post-Procedure Monitoring

• Monitor the implantation site for signs of bleeding or hematoma formation
• If significant bleeding occurs, consider holding the next dose of Lovenox but continue aspirin if possible
• Resume full anticoagulation as soon as hemostasis is adequate

In summary, the priority is to maintain protection against valve thrombosis while minimizing perioperative bleeding risk. Continuing aspirin while temporarily interrupting Lovenox provides the optimal balance between these competing concerns.