Lovenox Discontinuation Before CABG Surgery
Timing of Discontinuation
- The American College of Cardiology and American Heart Association recommend stopping enoxaparin 12-24 hours prior to elective CABG and dosing with unfractionated heparin according to institutional protocol, for patients with unstable angina/NSTEMI who require CABG, as well as broadly for CABG patients on enoxaparin 1, 2
- The 12-24 hour window allows adequate clearance of enoxaparin's anticoagulant effect while maintaining anticoagulation coverage through UFH, for patients undergoing CABG 1, 2
Transition to Unfractionated Heparin
- The American College of Cardiology and American Heart Association recommend continuing UFH perioperatively rather than leaving patients without anticoagulation during the enoxaparin washout period, to maintain thrombotic protection while optimizing surgical hemostasis 1, 2
- UFH is preferred over enoxaparin in the immediate perioperative period because it has a shorter half-life and can be more easily reversed if needed, for patients undergoing CABG 1, 2
Comparison with Other Anticoagulants
- For patients undergoing CABG, fondaparinux should be discontinued 24 hours before CABG and bridged with UFH, while bivalirudin should be discontinued 3 hours before CABG and bridged with UFH 1, 2
Critical Pitfalls to Avoid
- The American College of Cardiology and American Heart Association advise against continuing enoxaparin up to the time of surgery, as the longer half-life compared to UFH increases bleeding risk during CABG, and against leaving patients without anticoagulation during the washout period 1, 2
- It is also important not to confuse enoxaparin timing with antiplatelet timing, as clopidogrel requires 5-7 days discontinuation and aspirin is typically continued, while enoxaparin only needs 12-24 hours 1, 2, 3