Our own suggestions for management guidelines in this setting are summarized in Table 1
. These make certain assumptions, and are (very) limited by extrapolation of evidence from diverse observations from different clinical studies, in different settings. Firstly, anticoagulation is a reasonable strategy in ACS6,14 and may be an alternative to aspirin, as evident by some clinical trials, such as the Warfarin, Aspirin, Reinfarction Study (WARIS-II).6–7 Secondly, the main benefit of aspirin after myocardial infarction is seen in the first 35 days, with little further mortality benefit or loss during subsequent years.15In ACS patients, there is evidence of a benefit of aspirin-clopidogrel use for up to 9 months, as shown in the Clopidogrel in Unstable Angina To Prevent Recurrent Events study16(and the Clopidogrel in Unstable Angina To Prevent Recurrent Events-PCI study17), but the benefit seen (death from cardiovascular causes, nonfatal myocardial infarction, or stroke occurred in 9.3% of the clopidogrel group vs 11.4% in the placebo group) needs to be put in context with the increased risk of bleeding (3.7% in the clopidogrel group vs 2.7% in the placebo group) with combination aspirin-clopidogrel therapy.16–18 In the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance trial,19 clopidogrel (75 mg/d) plus aspirin (75 to 162 mg/d) was not significantly more effective than aspirin alone in reducing the rate of myocardial infarction, stroke, or death from cardiovascular causes in 15,603 patients with either clinically evident cardiovascular disease or multiple risk factors, with an increase in moderate-to-severe bleeding. There is also a very well-argued analysis that clopidogrel therapy beyond a few months after PCI does not influence mortality, has a questionable effect on the incidence of myocardial infarction, and is not cost-effective, but results in a significant increase in major bleeding.18 In contrast to clopidogrel, aspirin may have more direct effects on the gastric mucosa, leading to erosions and bleeding; however, one recent analysis20 among patients with a history of aspirin-induced ulcer bleeding whose ulcers had healed, aspirin plus esomeprazole (a proton-pump inhibitor) was superior to clopidogrel in the prevention of recurrent ulcer bleeding.