What medications should be prescribed to an Acute Coronary Syndrome (ACS) patient upon discharge home?

Medications for ACS Patients Upon Discharge

Upon discharge, ACS patients should receive dual antiplatelet therapy (DAPT) consisting of aspirin (81mg daily preferred) plus a P2Y12 inhibitor (ticagrelor preferred over clopidogrel), sublingual nitroglycerin, and other medications to control ischemia including beta-blockers and ACE inhibitors, with medication duration and selection tailored to the patient's specific risk factors and treatment strategy. 1

Core Discharge Medications

Antiplatelet Therapy

• Aspirin: Continue indefinitely at a maintenance dose of 81 mg daily (preferred) for patients treated with ticagrelor, or 81-325 mg daily for all other patients 1
• P2Y12 Inhibitor: Should be continued for up to 12 months in all ACS patients without contraindications 1
  • Ticagrelor (90 mg twice daily) is reasonable to use in preference to clopidogrel for patients with NSTE-ACS who undergo an early invasive or ischemia-guided strategy 1
  • Prasugrel (10 mg daily) is reasonable over clopidogrel for patients with NSTE-ACS who undergo PCI and are not at high risk for bleeding complications 1
  • Clopidogrel (75 mg daily) is an alternative when ticagrelor or prasugrel are contraindicated 1, 2

Anti-Ischemic Medications

• Sublingual or spray nitroglycerin: All post-ACS patients should receive this with verbal and written instructions for its use 1
• Beta-blockers: Indicated for all patients recovering from ACS unless contraindicated 1
  • For patients with moderate or severe LV failure, use a gradual titration scheme 1
• ACE inhibitors: Should be given and continued indefinitely for patients with heart failure, LVEF <0.40, hypertension, or diabetes mellitus 1
  • Reasonable for all ACS patients even without these conditions 1
• Angiotensin receptor blockers (ARBs): Should be prescribed for patients intolerant to ACE inhibitors who have clinical or radiological signs of heart failure and LVEF <0.40 1
• Aldosterone receptor blockers: Recommended for patients without significant renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor, have LVEF ≤0.40, and have either symptomatic heart failure or diabetes 1

Duration of Antiplatelet Therapy

• DAPT Duration: Generally recommended for 12 months in all ACS patients 1, 3
• Shorter Duration: 3-6 months of DAPT may be reasonable if bleeding risk is high 3
• Extended Duration: Prolonged DAPT beyond 12 months may be considered for patients at low bleeding risk 3
• Early Discontinuation: If bleeding risk outweighs benefit, earlier discontinuation (<12 months) of P2Y12 inhibitor therapy is reasonable 1

Special Considerations

Stent Placement

• For patients receiving a stent (bare-metal or drug-eluting) during PCI for NSTE-ACS, P2Y12 therapy should be given for at least 12 months with options including:
  • Clopidogrel: 75 mg daily
  • Prasugrel: 10 mg daily
  • Ticagrelor: 90 mg twice daily 1

Bleeding Risk Assessment

• High bleeding risk factors include: age ≥65 years, low body weight (BMI <18.5), diabetes, prior bleeding, or concurrent oral anticoagulant use 3
• Prasugrel should be avoided in patients with history of stroke/TIA, age >75 years, or weight <60 kg due to increased bleeding risk 3

Diabetes Considerations

• For patients with diabetes and ACS, the same antiplatelet recommendations apply, with P2Y12 inhibitors (ticagrelor or prasugrel) in combination with aspirin recommended for at least 1 year following an ACS 1

Patient Education and Follow-up

• Before discharge, patients should be informed about symptoms of worsening myocardial ischemia and MI 1
• Provide verbal and written instructions about medication type, purpose, dose, frequency, side effects, and duration of use 1
• Instruct patients that for angina lasting >1 minute, they should take one dose of nitroglycerin; if not improved within 3-5 minutes, call emergency services 1
• Educate patients about cardiovascular risk factor modification 1
• If pattern or severity of angina changes, patients should contact their clinician without delay 1

Common Pitfalls to Avoid

• Inadequate antiplatelet coverage: Failure to prescribe DAPT for ACS patients significantly increases risk of recurrent events 1, 3
• Inappropriate P2Y12 inhibitor selection: Not considering bleeding risk when choosing between ticagrelor, prasugrel, and clopidogrel 3
• Overlooking patient education: Patients must understand when and how to take medications, especially nitroglycerin for angina 1
• Neglecting beta-blockers or ACE inhibitors: These medications provide significant mortality benefit in post-ACS patients 1
• Missing contraindications: Prasugrel should be avoided in patients with prior stroke/TIA, age >75 years, or weight <60 kg 3

By following these evidence-based recommendations for discharge medications after ACS, clinicians can significantly reduce the risk of recurrent cardiovascular events and improve patient outcomes.