From the Guidelines
For a patient with unstable angina after ACS protocol activation, the discharge medications should include dual antiplatelet therapy with aspirin 75mg daily and ticagrelor 90mg twice daily for 12 months, as per the most recent guidelines 1. The current fondaparinux should be discontinued at discharge as it's primarily used during the acute hospital phase. The patient should continue atorvastatin 80mg daily long-term for lipid management and amlodipine 5mg daily for blood pressure control. Additional standard medications would typically include a beta-blocker (such as bisoprolol 2.5-5mg daily) and an ACE inhibitor (such as ramipril 2.5-10mg daily) unless contraindicated. The patient should also receive a proton pump inhibitor like lansoprazole 30mg daily for gastric protection while on dual antiplatelet therapy. These medications work together to prevent further coronary events by inhibiting platelet aggregation, controlling blood pressure, reducing myocardial oxygen demand, stabilizing atherosclerotic plaques, and protecting against gastrointestinal bleeding risks associated with antiplatelet therapy, as recommended by the American College of Cardiology solution set oversight committee 1. Key considerations for the discharge medications include:
- Dual antiplatelet therapy for 12 months to reduce the risk of further coronary events
- Long-term lipid management with atorvastatin 80mg daily
- Blood pressure control with amlodipine 5mg daily
- Gastric protection with a proton pump inhibitor like lansoprazole 30mg daily
- Consideration of beta-blocker and ACE inhibitor therapy unless contraindicated, based on the latest expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atherosclerotic cardiovascular disease 1.
From the Research
Discharge Orders for Unstable Angina
The discharge orders for a patient with unstable angina, as per NHS guidelines, will depend on the individual patient's condition and medical history. However, based on the provided evidence, the following discharge medications may be considered:
- Aspirin: The patient is already on aspirin, which is recommended for patients with unstable angina as it reduces the incidence of myocardial infarction by 51% 2.
- Ticagrelor: The patient is already on ticagrelor 90mg BD, which is a recommended antiplatelet therapy for patients with unstable angina/NSTEMI 3.
- Fondaparinux: The patient is already on fondaparinux, which is an anticoagulant that may be used in patients with acute coronary syndromes.
- Amlodipine: The patient is already on amlodipine 5mg, which is a calcium channel blocker that may be used to control blood pressure and reduce angina symptoms.
- Atorvastatin: The patient is already on atorvastatin 80mg, which is a statin that may be used to lower cholesterol levels and reduce the risk of cardiovascular events.
Discharge Care Plan
The discharge care plan should include:
- Continued monitoring of symptoms: Patients with unstable angina should be monitored for symptoms such as chest pain, shortness of breath, and fatigue 4.
- Appropriate drug therapy: The patient should continue to take their prescribed medications, including aspirin, ticagrelor, fondaparinux, amlodipine, and atorvastatin.
- Risk-factor modification: The patient should be advised to modify their risk factors, such as smoking, high blood pressure, and high cholesterol, to reduce their risk of cardiovascular events 4.
- Counseling: The patient should receive counseling on their condition, treatment, and lifestyle modifications to reduce their risk of cardiovascular events 4.