Coumarin Therapy in Acute Myocardial Infarction: A Hobson's Choice

After 25 years of extensive investigation, coumarin therapy has failed to demonstrate a statistically significant decrease either in deaths or residual strokes among patients with acute myocardial infarction. The principal reason for failure has been faulty clinical trial design, especially the small numbers of patients utilized and the limited recognition of the clinical implications of the pathophysiology of thromboembolism. Yet the numbers of patients at risk from thromboembolism are sufficiently great and the favorable clinical impressions are sufficiently strong that, conversely, the possibility of benefit cannot be excluded. In this therapeutic dilemma, we believe one acceptable course is to use anticoagulant therapy to treat all patients having proved acute myocardial infarction while they are hospitalized, unless there are contraindications to the therapy.