Question: J.P. is a 62-year-old male with a history of atrial fibrillation, mechanical AVR (St. Jude, 2015), CVA, and seizures. Current medications include warfarin 5mg daily, metoprolol XL 100mg once daily, atorvastatin 80mg QHS, and phenytoin 300mg once daily. INR goal is 2.0 - 3.0, and INR today is 2.1. CrCl is 65 ml/min. J.P. presents today to establish care with his new cardiologist. What recommendations might be made regarding J.P.'s anticoagulation therapy? a. Stop warfarin and switch to rivaroxaban (Xarelto) 20mg once daily. b. Change INR goal to 2.5-3.5 and increase warfarin dose to 5mg daily except 7.5mg on Mondays. c. Continue current anticoagulation regimen. d. Stop warfarin and switch to dabigatran (Pradaxa) 150mg BID.