From the Guidelines
The discharge orders for a patient with unstable angina after ACS protocol activation should include dual antiplatelet therapy with aspirin 81mg daily indefinitely and a P2Y12 inhibitor (such as clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily) for at least 12 months, as recommended by the most recent guidelines 1.
Medications
- A high-intensity statin like atorvastatin 40-80mg or rosuvastatin 20-40mg daily should be prescribed to stabilize atherosclerotic plaques and reduce myocardial oxygen demand.
- Beta-blockers such as metoprolol 25-100mg twice daily are recommended to reduce myocardial oxygen demand.
- An ACE inhibitor (like lisinopril 5-40mg daily) or ARB should be included, especially for patients with hypertension, diabetes, or left ventricular dysfunction.
Nitroglycerin
- Sublingual nitroglycerin 0.4mg should be provided for breakthrough angina with instructions to take one tablet every 5 minutes for a maximum of 3 doses, then seek emergency care if pain persists, as suggested by the guidelines 1.
Follow-up
- The patient should follow up with cardiology within 1-2 weeks and with their primary care physician within 1 week of discharge.
- Enrollment in a cardiac rehabilitation program after discharge can enhance patient education and compliance with the medical regimen.
- Telephone follow-up can serve to reinforce in-hospital instruction, provide reassurance, and answer the patient’s questions.
Education
- Patients should be educated about modification of cardiovascular risk factors, such as hypertension, smoking, dyslipidemia, physical inactivity, and diabetes mellitus, as recommended by the guidelines 1.
- Patients should be informed about symptoms of worsening myocardial ischemia and MI and should be instructed in how and when to seek emergency care and assistance if such symptoms occur.
- Patients should receive instructions about what to do if ischemic symptoms occur in the future, and face-to-face patient instruction should be reinforced and documented with written instruction sheets.
From the FDA Drug Label
The CURE study included 12,562 patients with ACS without ST-elevation (UA or NSTEMI) and presenting within 24 hours of onset of the most recent episode of chest pain or symptoms consistent with ischemia Patients were randomized to receive clopidogrel (300 mg loading dose followed by 75 mg once daily) or placebo, and were treated for up to one year Patients also received aspirin (75 to 325 mg once daily) and other standard therapies such as heparin.
The discharge orders for a patient with unstable angina and ACS protocol activated will be:
- Clopidogrel: 75 mg once daily
- Aspirin: 75 to 325 mg once daily 2
From the Research
Discharge Orders for Unstable Angina
The discharge orders for a patient with unstable angina, following the activation of the ACS protocol, typically involve antiplatelet therapy to reduce the risk of further cardiac events.
- The use of aspirin, clopidogrel, or other P2Y12 inhibitors is common in these cases, as evidenced by studies such as 3, which reviews the role of antiplatelet agents in patients with non-ST elevation acute coronary syndrome.
- The combination of clopidogrel and aspirin has been shown to be beneficial in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome, as seen in the CURE trial 4.
- Newer P2Y12 inhibitors, such as prasugrel or ticagrelor, may also be used, but their use is associated with a higher risk of bleeding, as noted in 5 and 6.
- The choice of discharge medication will depend on the individual patient's risk factors and medical history, as well as the specific treatment strategy employed by the healthcare provider.
Medication Options
Some possible medication options for discharge include:
- Aspirin, as a foundation of antiplatelet therapy
- Clopidogrel, as an alternative or addition to aspirin
- Newer P2Y12 inhibitors, such as prasugrel or ticagrelor, for patients at high risk of cardiac events
- Anticoagulant therapy, such as rivaroxaban, in combination with low-dose aspirin, as seen in 7
Considerations
When determining the discharge orders, the healthcare provider will consider the patient's: