What is the recommended Acute Coronary Syndrome (ACS) regimen for a patient with a history of hypertension and heart failure?

Recommended ACS Regimen for Patients with Hypertension and Heart Failure

All patients with acute coronary syndrome should receive immediate dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor), high-intensity statin therapy, beta-blockers, and ACE inhibitors or ARBs, with specific attention to the patient's heart failure status and bleeding risk. 1, 2

Immediate Antiplatelet Therapy

Aspirin

• Administer aspirin 162-325 mg loading dose immediately (chewed for faster absorption), followed by 75-100 mg daily maintenance dose. 3, 1
• Aspirin should be continued indefinitely unless contraindicated 1, 2
• Use uncoated formulation for acute presentation 3

P2Y12 Inhibitor Selection

For ACS patients undergoing PCI with stent placement, choose one of the following P2Y12 inhibitors for at least 12 months: 1, 2

• Ticagrelor 90 mg twice daily (preferred in most ACS patients; keep aspirin ≤100 mg daily when using ticagrelor) 1, 2
• Prasugrel 60 mg loading dose, then 10 mg daily (avoid if history of stroke/TIA, age >75 years, or weight <60 kg; consider 5 mg daily if weight <60 kg) 1, 4, 5
• Clopidogrel 75 mg daily (after appropriate loading dose of 600 mg) if ticagrelor or prasugrel contraindicated 1

Critical consideration: Prasugrel showed superior outcomes compared to ticagrelor in the ISAR-REACT-5 trial (6.9% vs 9.3% event rate, p=0.006) but has important contraindications 5, 4

Anticoagulation During Acute Phase

• Administer parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux during the acute hospitalization. 6

Beta-Blocker Therapy

Beta-blockers are mandatory in all ACS patients, especially those with heart failure or reduced ejection fraction (LVEF ≤40%). 1, 2

• Preferred agents: carvedilol, metoprolol succinate, or bisoprolol (proven mortality reduction) 1, 2, 7
• Avoid atenolol due to inferior outcomes 2, 7
• Continue for at least 3 years post-ACS, and indefinitely if heart failure present 1, 2
• Use agents and doses with proven efficacy in heart failure trials 1

ACE Inhibitor or ARB Therapy

ACE inhibitors should be started immediately and continued indefinitely in all ACS patients, particularly those with heart failure, hypertension, diabetes, or LVEF ≤40%. 1, 2

• ACE inhibitors are Class I recommendation for patients with LV systolic dysfunction, heart failure, hypertension, diabetes, or chronic kidney disease 1
• ARBs are appropriate alternatives if ACE inhibitors are not tolerated 1, 2
• Never combine ACE inhibitors with ARBs—this is contraindicated 1, 2

Aldosterone Antagonist for Heart Failure

Add aldosterone blockade (spironolactone or eplerenone) if LVEF ≤40% and patient has diabetes or heart failure, provided no significant renal dysfunction or hyperkalemia. 1

High-Intensity Statin Therapy

Initiate high-intensity statin therapy (reducing LDL-C by ≥50%) as early as possible during hospitalization, targeting LDL-C <55 mg/dL. 1, 2

• High-dose atorvastatin 80 mg daily or equivalent high-intensity statin 1
• If LDL-C goal not achieved on maximum tolerated statin, add ezetimibe 1, 2
• For very high-risk patients not at goal on statin plus ezetimibe, add PCSK9 inhibitor 1, 2
• Early intensive statin therapy (started before discharge) improves compliance and outcomes 1

Blood Pressure Management in This Population

Target Blood Pressure

• Standard target: <140/90 mmHg 1, 7
• Consider lower target <130/80 mmHg in select patients with prior stroke/TIA or high-risk features 1, 2, 7
• Critical warning: Do not lower diastolic BP below 60 mmHg (may worsen myocardial ischemia) 2, 7

Antihypertensive Regimen

The foundational triple therapy for hypertension in ACS patients consists of: 1, 7

1. Beta-blocker (already prescribed for ACS indication)
2. ACE inhibitor or ARB (already prescribed for ACS/heart failure indication)
3. Thiazide or thiazide-like diuretic (chlorthalidone preferred) 1, 7

Add-On Therapy if BP Uncontrolled

If hypertension or angina remains uncontrolled on triple therapy, add a long-acting dihydropyridine calcium channel blocker (amlodipine). 1, 7

• Do not use nondihydropyridine CCBs (diltiazem, verapamil) if LV dysfunction present (Class III Harm) 1, 2, 7
• Avoid combining beta-blockers with nondihydropyridine CCBs due to bradyarrhythmia risk 1, 2, 7

Diuretic Therapy for Heart Failure

Diuretic therapy is mandatory in patients with signs of pulmonary or systemic congestion to relieve heart failure symptoms. 1

Gastrointestinal Protection

Prescribe a proton pump inhibitor for patients receiving dual antiplatelet therapy who are at high risk of gastrointestinal bleeding. 1, 6

• High-risk features include: age ≥65 years, prior GI bleeding, concurrent anticoagulation, or chronic NSAID use 6

Nitrates for Symptom Relief

• Long-acting nitrates or sublingual nitroglycerin can be used for angina relief 1, 6
• Nitrates do not affect hypertension management significantly 1
• Never use nitrates with phosphodiesterase-5 inhibitors (sildenafil) 1

Duration of Dual Antiplatelet Therapy

Continue dual antiplatelet therapy for at least 12 months after ACS with PCI and stent placement. 1, 2, 5

• If high bleeding risk: consider shorter duration (3-6 months) 5
• If low bleeding risk and no bleeding events: may consider prolonged DAPT beyond 12 months 5
• High bleeding risk defined as: age ≥65 years, weight <60 kg, diabetes, prior bleeding, or concurrent anticoagulation 5

Critical Pitfalls to Avoid

Medication Selection Errors

• Never use atenolol as the beta-blocker (inferior outcomes) 2, 7
• Never combine beta-blockers with nondihydropyridine CCBs unless absolutely necessary 1, 2, 7
• Never use nondihydropyridine CCBs in patients with LV dysfunction 1, 2, 7
• Never combine ACE inhibitors with ARBs 1, 2

Prasugrel-Specific Contraindications

• Absolutely contraindicated if history of stroke or TIA (6.5% stroke rate vs 1.2% with clopidogrel) 4, 5
• Generally not recommended if age >75 years (increased fatal and intracranial bleeding) 4
• Reduce dose to 5 mg daily if weight <60 kg 4

Blood Pressure Management Errors

• Do not lower diastolic BP below 60 mmHg (worsens myocardial ischemia) 2, 7
• Do not lower systolic BP below 130 mmHg in octogenarians 2

Antiplatelet Management

• Avoid NSAIDs for pain management (increased MACE risk); use acetaminophen or short-acting opioids instead 3
• Do not discontinue antiplatelet therapy prematurely (increases risk of subsequent CV events, especially in first few weeks) 4

Additional Risk Factor Modification

• Smoking cessation is mandatory 1, 2
• Target HbA1c ~7% in diabetic patients 1, 2
• Recommend Mediterranean diet with olive oil and nuts 2
• Prescribe regular aerobic exercise ≥150 minutes/week moderate intensity 1, 2
• Target BMI 18.5-24.9 kg/m² and waist circumference <40 inches (men) or <35 inches (women) 1, 2