What is the management plan for a patient discharged after an acute coronary syndrome (ACS) rule out with an ejection fraction (EF) of 65%, started on Aspirin (ASA) 81mg, metoprolol (Lopressor) 12.5mg twice daily (BID), and Rosuvastatin (Crestor) 20mg?

Management After ACS Rule-Out with Normal EF

Continue the current regimen of aspirin 81mg daily, metoprolol 12.5mg BID, and rosuvastatin 20mg daily, but add a P2Y12 inhibitor (ticagrelor 90mg BID preferred, or clopidogrel 75mg daily if ticagrelor contraindicated) for dual antiplatelet therapy, and consider adding an ACE inhibitor if the patient has diabetes or hypertension. 1, 2

Critical Missing Component: Dual Antiplatelet Therapy

• The patient is missing a P2Y12 inhibitor, which is a Class I recommendation for all patients after ACS rule-out, even with an ischemia-guided strategy 1
• Ticagrelor 90mg twice daily is preferred over clopidogrel based on mortality benefit in contemporary guidelines 1, 2
• If ticagrelor is not tolerated or contraindicated, clopidogrel 75mg daily is an acceptable alternative 1
• Dual antiplatelet therapy should continue for up to 12 months in all patients with NSTE-ACS without contraindications 1

Aspirin Dosing Optimization

• The current aspirin dose of 81mg daily is appropriate and should be continued indefinitely 1
• When used with ticagrelor, the maintenance dose must be 81mg daily (not higher) 1
• Lower aspirin doses (75-162mg) have similar efficacy to higher doses but significantly less bleeding risk—major bleeding rates were 2.0% with <100mg versus 4.0% with >200mg daily 1

Beta-Blocker Therapy Assessment

• Metoprolol 12.5mg BID is a reasonable starting dose but requires upward titration 2
• With a normal EF of 65%, beta-blockers are not mandated by guidelines (Class I recommendation only for LVEF ≤40%) 1
• However, beta-blockers remain beneficial for symptom control and are reasonable to continue, titrating to target heart rate of 50-60 bpm as tolerated 1, 2
• Avoid beta-blockers if there are signs of coronary vasospasm or recent cocaine use 1

Statin Therapy Verification

• Rosuvastatin 20mg daily represents high-intensity statin therapy and is appropriate 1
• Target LDL-C reduction of ≥50% from baseline and achieve LDL-C <55 mg/dL (<1.4 mmol/L) 1
• Continue statin therapy indefinitely as a Class I recommendation 1
• Monitor liver function tests given the statin therapy, particularly if baseline abnormalities exist 3

ACE Inhibitor Consideration

• An ACE inhibitor is Class I recommended if the patient has LVEF ≤40%, heart failure, hypertension, or diabetes 1
• With EF 65%, ACE inhibitor is only indicated if comorbid hypertension or diabetes is present 1
• If ACE inhibitor is indicated but not tolerated, use an ARB as alternative 1

Additional Secondary Prevention Measures

• Proton pump inhibitor should be added if the patient is at high risk for gastrointestinal bleeding (age >65, prior GI bleed, concurrent NSAID use, or anticoagulation) 1
• Lifestyle modifications are Class I recommendations: smoking cessation, regular physical activity (≥30 minutes, ≥3 times weekly), and healthy diet 1
• Enroll in cardiac rehabilitation program to enhance compliance and promote lifestyle changes 1
• Blood pressure target: diastolic <90 mmHg (<85 mmHg if diabetic) 1

Common Pitfalls to Avoid

• Do not discharge ACS patients on aspirin monotherapy—this is the most critical error in this case 1, 2
• Do not use aspirin doses >81mg when combining with ticagrelor, as this increases bleeding without improving efficacy 1
• Do not assume beta-blockers are mandatory with normal EF—they are beneficial but not Class I indicated 1
• Ensure medication adherence counseling, as discontinuation rates reach 17.8% for P2Y12 inhibitors and 6.6% for statins by one year, often due to physician decisions rather than patient-initiated stops 4