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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