From the Guidelines
For a patient with unstable angina following ACS protocol activation, the discharge medications should include aspirin, ticagrelor 90mg twice daily, fondaparinux, amlodipine 5mg, and atorvastatin 80mg, as mentioned, and an ACE inhibitor (such as ramipril 2.5-10mg daily) and a beta-blocker (such as bisoprolol 1.25-10mg daily) should be added to the regimen. The current medications are appropriate for managing unstable angina, but the addition of an ACE inhibitor and a beta-blocker is crucial for reducing morbidity and mortality in post-ACS patients. ACE inhibitors are essential as they reduce mortality in post-ACS patients by preventing adverse cardiac remodeling, reducing blood pressure, and decreasing afterload on the heart, as supported by studies such as 1. They're particularly important for patients with left ventricular dysfunction, diabetes, or hypertension. Beta-blockers are equally crucial as they decrease myocardial oxygen demand by reducing heart rate and contractility, which helps prevent recurrent ischemia and arrhythmias, as recommended in guidelines such as 1. They've been shown to reduce mortality and reinfarction rates post-ACS. Both medications should be titrated gradually to target doses as tolerated, monitoring for side effects such as hypotension, bradycardia, or worsening renal function. The complete regimen provides comprehensive secondary prevention by addressing multiple pathophysiological mechanisms involved in coronary artery disease. Key points to consider in the management of unstable angina include:
- The use of aspirin, ticagrelor, and fondaparinux for antiplatelet and anticoagulant therapy, as recommended in guidelines such as 1
- The importance of ACE inhibitors and beta-blockers in reducing morbidity and mortality, as supported by studies such as 1
- The need for comprehensive secondary prevention, including lifestyle modifications and management of risk factors, to reduce the risk of recurrent cardiovascular events.
From the Research
Discharge Orders for Unstable Angina
The patient is currently on aspirin, fondaparinux, ticagrelor 90mg BD, amlodipine 5mg, and atorvastatin 80mg.
- The discharge medications should include continued monitoring of symptoms and appropriate drug therapy, including aspirin 2.
- The use of a combination of aspirin, a statin, and blood pressure-lowering agents is associated with a lower risk of vascular morbidity and mortality in patients with coronary artery disease 3.
Need for ACEI and Beta Blockers
- The management of suspected unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI) includes the use of beta blockers and angiotensin-converting enzyme inhibitors (ACEI) or statins in selected patients 4.
- ACEI and beta blockers are not currently part of the patient's medication regimen, but they may be considered for discharge based on the patient's individual needs and risk factors.
- The decision to use ACEI and beta blockers should be based on the patient's clinical course and results of noninvasive testing 2, 4.
Current Medication Regimen
- The patient is currently taking ticagrelor, which is a cyclopentyl-triazolo-pyrimidine antiplatelet agent indicated for the prevention of atherothrombotic events in adults with acute coronary syndromes (ACS) 5.
- The patient's current medication regimen also includes aspirin, fondaparinux, amlodipine, and atorvastatin, which are all commonly used in the management of unstable angina and ACS 2, 4, 3.