What are the current evidence-based recommendations for aspirin and clopidogrel (Plavix) use following coronary artery bypass graft (CABG) surgery (both on- and off-pump procedures)? If possible, please include medication dosages and length of treatment. — Merianne Lorenzen, PA-C, Bryn Mawr, Pa.

Such studies as the CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events; Circulation. 2004;110:1202-1208), CASCADE (Clopidogrel After Surgery for Coronary Artery DiseasE; Curr Control Trials Cardiovasc Med. 2005;6:15), and various meta-analyses of the efficacy of clopidogrel and aspirin have addressed this topic.

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Multivariate analysis states that beyond 30 days, there is no significant difference in the end point with the use of aspirin vs. aspirin and clopidogrel. The CURE study subgroup analysis showed no benefit of clopidogrel following CABG.

The CASCADE study compared aspirin alone with a combination of aspirin and clopidogrel and showed no significant reduction in the process of saphenous vein intimal hyperplasia at one year. A retro­spective analysis involving more than 15,000 patients concluded that the relative effect of combined treatment did not differ between on- and off-pump (J Thorac Cardiovasc Surg. 2009;138:1377-1384). Other studies have concluded that there is no significant difference between clopidogrel alone compared to aspirin with clopidogrel in (saphenous) graft patency (Ann Thorac Surg. 2009; 88: 59-62).

It has been recommended to use aspirin indefinitely and clopidogrel for a minimum of one month to one year following CABG. However, each patient should be evaluated independently. The platelet count will dictate the therapy, as will the survival rate, coronary stent placement, risk of GI bleed, and a history of recent myocardial infarction. Aspirin dosage (81 mg vs. 325 mg) has not been clearly established, so assess each patient separately. — Debra King, PhD, PA (163-4)

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