The pendulum has been swinging on this issue for years. A meta-analysis published in the August 16 issue of Annals of Internal Medicine favors warfarin added to aspirin for patients with ACS. Patients who received coronary stents were excluded. Warfarin was associated with decreases in myocardial infarction, ischemic stroke and need for revascularization. Benefits outweighed the bleeding risks in all but those patients stratified as high risk for bleeding. There was no effect on mortality.
For patients with ACS who do not receive stents we now have two antithrombotic agents to consider adding to aspirin, these being clopidogrel and warfarin. Patient selection for treatment with one agent or the other will be complex, and will need to take into account risk factors, cost, and patient preference.