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Which patients should be on a regimen of aspirin or clopidogrel (Plavix)? What role does warfarin (Coumadin) play in those requiring anticoagulation therapy?
—Jill Schmidt, PA-C, Belmont, Mich.

Aspirin has an established role in preventing thrombotic events in cardiovascular disease. Patients with a history of MI, stroke, prosthetic valve (nonmechanical), CAD, atrial fibrillation (AF), coronary-artery stenting, coronary artery bypass grafting (CABG), or peripheral artery disease should be on a daily dose of 81 or 325 mg of aspirin (enteric-coated preferred).

Clopidogrel has been used as secondary prevention of atherosclerotic events in patients with a history of stroke, MI, or peripheral vascular disease and those at high risk of vascular events who have major contraindications to aspirin. Clopidogrel is temporarily prescribed post off-pump CABG (beating-heart surgery) and post coronary artery stenting. The FDA has not approved clopidogrel for the treatment of AF. Compared with aspirin therapy, clopidogrel is very expensive. Warfarin is reserved for mechanical-valve prosthesis, long-term AF therapy, prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic events. Patients on warfarin need to have their serum international normalized ratio/prothrombin time monitored for therapeutic dosing.
—Debra Kleinschmidt, PhD, PA (101-7)

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