From the Guidelines
For a patient with unstable angina following activation of the Acute Coronary Syndrome (ACS) protocol, the discharge medications should include aspirin 81mg daily indefinitely, ticagrelor 90mg twice daily for 12 months, atorvastatin 80mg daily, and amlodipine 5mg daily. The patient is already on aspirin, fondaparinux, ticagrelor 90mg twice daily, amlodipine 5mg, and atorvastatin 80mg, which is in line with the recommendations from the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. The guideline recommends that aspirin should be continued indefinitely at a maintenance dose of 81mg daily in patients treated with ticagrelor 1. Additionally, the guideline suggests that a P2Y12 inhibitor, such as ticagrelor, should be continued for up to 12 months in all patients with NSTE-ACS without contraindications who are treated with an ischemia-guided strategy 1. Key points to consider for discharge medications include:
- Aspirin 81mg daily indefinitely
- Ticagrelor 90mg twice daily for 12 months
- Atorvastatin 80mg daily for lipid management
- Amlodipine 5mg daily for blood pressure control Fondaparinux is typically used as an in-hospital anticoagulant and can be discontinued at discharge. It is also important to consider the addition of a beta-blocker and an ACE inhibitor to the discharge regimen, unless contraindicated, to reduce the risk of recurrent cardiac events by controlling blood pressure, reducing myocardial oxygen demand, and stabilizing atherosclerotic plaques.
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: continued use as an antiplatelet agent to prevent recurrent events 2, 3, 4
- Ticagrelor: continued use as a P2Y12 receptor inhibitor for dual antiplatelet therapy 4
- Fondaparinux: may be continued as an anticoagulant to prevent progression of coronary thrombus 5, 4
- Amlodipine: may be continued as a calcium channel blocker to control hypertension and reduce angina symptoms
- Atorvastatin: may be continued as a statin to reduce cholesterol levels and prevent recurrent events
Discharge Care Plan
The discharge care plan should include:
- Continued monitoring of symptoms and adjustment of medications as needed
- Risk-factor modification, such as lifestyle changes and management of hypertension, diabetes, and hyperlipidemia
- Counseling on medication adherence, lifestyle changes, and follow-up appointments
- Coordination of medical care and preparation of the patient for resumption of normal activities 3
Medication Management
The patient's medication regimen should be carefully managed to balance the benefits of antithrombotic therapy against the risk of bleeding complications. The use of combination therapy, such as aspirin, ticagrelor, and fondaparinux, should be carefully considered and monitored 4. Regular follow-up appointments and laboratory tests may be necessary to adjust the patient's medication regimen and prevent adverse events.