There has been considerable interest in the utility of newer oral anticoagulants for the secondary prevention of myocardial infarction (MI) and acute coronary syndromes (ACS). The direct thrombin inhibitor dabigatran has been approved for stroke prevention in patients with atrial fibrillation. However, as Verheugt discussed, when combined with dual antiplatelet therapy for secondary prevention in patients with ACS, no difference was found between the placebo and dabigatran groups for the composite end point of cardiovascular death, nonfatal MI, or stroke. However, it should also be noted that recent reports have actually suggested an increased risk of MI and ACS in patients treated with dabigatran. After the Randomized Evaluation of Long-term Anticoagulant Therapy (RE-LY) trial suggested an increased risk of MI or ACS with the use of dabigatran versus warfarin in patients with atrial fibrillation, a meta-analysis of 7 trials was conducted. These trials had included patients with ACS, patients with atrial fibrillation, and patients receiving prophylaxis for deep venous thrombosis. Notably, a greater risk of MI or ACS was associated with the use of dabigatran compared with the control group (dabigatran, 237 of 20,000 [1.19%] vs control, 83 of 10,514 [0.79%]; odds ratio 1.33; 95% confidence interval 1.03 to 1.71; p = 0.03). The authors of the meta-analysis concluded, “Clinicians should consider the potential of these serious harmful cardiovascular effects with use of dabigatran.”