From the Guidelines
For a patient experiencing chest pain post-acute coronary syndrome (ACS), the recommended medications include dual antiplatelet therapy, a high-intensity statin, beta-blockers, and sublingual nitroglycerin as needed. The cornerstone medications 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 1. A high-intensity statin like atorvastatin (40-80mg daily) or rosuvastatin (20-40mg daily) should be initiated to stabilize plaques and reduce cholesterol 1. Beta-blockers such as metoprolol (25-100mg twice daily) or carvedilol (3.125-25mg twice daily) help reduce myocardial oxygen demand and prevent arrhythmias 1. For ongoing chest pain, sublingual nitroglycerin (0.4mg as needed) provides immediate relief by dilating coronary arteries 1. These medications work together to prevent further cardiac events by reducing platelet aggregation, lowering lipid levels, decreasing myocardial oxygen demand, and improving cardiac remodeling. Regular monitoring of renal function, electrolytes, and liver enzymes is essential when using these medications. Some key considerations include:
- Administering supplemental oxygen only with oxygen saturation <90%, respiratory distress, or other high-risk features for hypoxemia 1
- Using nitrates, such as sublingual NTG every 5 min × 3 for continuing ischemic pain, and then assessing need for IV NTG 1
- Avoiding NSAIDs (except aspirin) due to the increased risk of MACE associated with their use 1
- Considering the use of calcium channel blockers (CCBs) for ischemic symptoms when beta blockers are not successful, are contraindicated, or cause unacceptable side effects* 1
From the FDA Drug Label
The GISSI-3 study was a multicenter, controlled, randomized, unblinded clinical trial conducted in 19,394 patients with acute myocardial infarction (MI) admitted to a coronary care unit Patients receiving lisinopril (n=9,646), alone or with nitrates, had an 11% lower risk of death (p = 0.04) compared to patients who did not receive lisinopril (n=9,672) (6.4% vs. 7. 2%, respectively) at six weeks
The medication lisinopril is recommended for patients experiencing chest pain post-acute coronary syndrome (ACS) as it has been shown to reduce the risk of death in patients with acute myocardial infarction 2.
- Key benefits:
- Reduced risk of death
- Improved outcomes in patients with systolic heart failure
- Important considerations:
- Patients should be hemodynamically stable
- Monitoring for hypotension and renal dysfunction is necessary
From the Research
Medications for Chest Pain Post-ACS
The following medications are recommended for patients experiencing chest pain post-acute coronary syndrome (ACS):
- Aspirin, unless contraindicated, as it improves survival 3, 4
- A second antiplatelet agent (e.g., clopidogrel, ticagrelor, or prasugrel) for dual antiplatelet therapy 3
- Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux 3
- Proton pump inhibitors to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher risk of gastrointestinal bleeding 3
- Statins, angiotensin-converting enzyme inhibitors, and beta blockers to reduce mortality and improve outcomes 3, 5, 6
- Nitroglycerin and morphine to relieve chest pain 3
- Oxygen therapy as needed 3
Additional Considerations
- Coronary angiography with percutaneous or surgical revascularization may be necessary for patients with ACS 3, 5
- Cardiac rehabilitation, smoking cessation, and annual influenza vaccination can reduce mortality and improve outcomes in patients who have had a recent myocardial infarction 5
- A combination therapy with aspirin, an ACE inhibitor, and a statin can reduce 1-year mortality in patients after acute myocardial infarction 6