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, plus the addition of an ACE inhibitor and beta-blocker. The current medications include aspirin, ticagrelor 90mg twice daily, fondaparinux, amlodipine 5mg, and atorvastatin 80mg. The need for ACE inhibitors and beta-blockers is supported by evidence from studies such as 1, which recommends the use of ACE inhibitors and beta-blockers in patients with symptomatic chronic stable angina to prevent MI or death and to reduce symptoms. ACE inhibitors (such as ramipril 2.5-10mg daily or perindopril 2-8mg daily) are recommended because they reduce mortality, prevent left ventricular remodeling, and decrease the risk of heart failure in post-ACS patients, particularly those with reduced ejection fraction, diabetes, or hypertension. Beta-blockers (such as bisoprolol 1.25-10mg daily or metoprolol 25-200mg daily) are essential as they reduce myocardial oxygen demand, decrease heart rate and blood pressure, improve coronary perfusion, and have been shown to reduce mortality and reinfarction rates. These medications should be started at low doses and titrated upward as tolerated, with monitoring for side effects such as hypotension, bradycardia, or worsening renal function. The complete regimen addresses multiple pathways in cardiovascular disease progression, including antiplatelet therapy, anticoagulation, blood pressure control, lipid management, and neurohormonal modulation, providing comprehensive secondary prevention following an acute coronary event. Key points to consider when prescribing these medications include:
- Starting with low doses and titrating upward as tolerated
- Monitoring for side effects such as hypotension, bradycardia, or worsening renal function
- Adjusting the regimen based on the patient's individual needs and response to treatment
- Ensuring comprehensive secondary prevention by addressing multiple pathways in cardiovascular disease progression.
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 events and total 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 risk factors, as well as guidelines for the management of UA/NSTEMI 4, 5.
Current Medications
- The patient is currently taking ticagrelor, which is a reversible antagonist of the P2Y(12) receptor and is indicated for the prevention of atherothrombotic events in adults with acute coronary syndromes (ACS) 6.
- The patient's current medications, including aspirin, fondaparinux, ticagrelor, amlodipine, and atorvastatin, should be continued as part of the discharge plan, with adjustments made as needed based on the patient's individual needs and response to treatment 2, 4, 6.