The presence of intracardiac thrombus has been associated with many diseases and clinical states, although cardiac impairment is commonly also present. Despite this, there continues to be a lack of consensus on which patients with cardiac impairment should have anticoagulant therapy. This review discusses the relationship between thromboembolism and cardiac impairment secondary to ischaemic heart disease, and suggests possible mechanisms, methods of diagnosis and therapeutic strategies for anticoagulation in such patients. In particular, warfarin has been established as thromboprophylaxis in certain subgroups of patients with cardiac impairment secondary to ischaemic heart disease. A large-scale randomised controlled trial in ambulant patients with cardiac impairment to evaluate the effectiveness of anticoagulant therapy and antiplatelet therapy is, however, long overdue.