In this section, we speci cally address patients with AF and ACS who do not undergo placement of an intracoro- nary stent. The indirect data summarized in Table 12 sug- gest that triple therapy may not be associated with net clinical bene t compared with dual antiplatelet therapy unless patients are at substantially high risk of stroke (eg, CHADS2 score of 2), whereas the net bene t at lower levels of stroke risk is uncertain. Rather than triple therapy, a third therapeutic option in this clinical scenario (where stent thrombosis is not a concern) is to use a VKA plus single antiplatelet therapy. Unfortunately, there are no RCTs com- paring warfarin plus single antiplatelet therapy to dual antiplatelet therapy. As described in Author et al (section 2.4) in this guideline, warfarin plus aspirin is associated with a signi cant reduction in risk of sub- sequent MI (relative risk, 0.69; 95% CI, 0.54-0.88) and stroke (relative risk, 0.56; 95% CI, 0.39-0.82) compared with aspirin alone in patients post-ACS.121 The point estimates for these reductions in MI and stroke are greater than those seen with clopidogrel plus aspirin (relative risk, 0.77; 95% CI, 0.67-0.89) vs aspirin alone (relative risk, 0.86; 95% CI, 0.63-1.18) in the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial.124 These data sug- gest that warfarin plus aspirin is at least as effec- tive, and potentially more effective, than clopidogrel plus aspirin for the prevention of cardiovascular events after ACS. Warfarin plus aspirin was not given a recommendation in Author et al either as an alterna- tive or in preference to dual antiplatelet therapy for patients post-ACS because of pragmatic issues (physician reluctance, burden of use, etc). 