What is the recommended post‑hospital management for a patient treated for acute coronary syndrome?

Post-Hospital Management Guidelines for Acute Coronary Syndrome

All patients with ACS should be discharged on dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor), high-intensity statin, beta-blocker, and ACE inhibitor (if indicated), with mandatory referral to cardiac rehabilitation before leaving the hospital. 1, 2

Discharge Medications

Antiplatelet Therapy

• Aspirin 81 mg daily should be continued indefinitely in all ACS patients 1, 2
• A P2Y12 inhibitor must be prescribed for at least 12 months to reduce major adverse cardiovascular events 1, 2
  • Ticagrelor 90 mg twice daily is preferred over clopidogrel for patients with NSTE-ACS undergoing early invasive or ischemia-guided strategy 2
  • Prasugrel 10 mg daily is reasonable over clopidogrel for patients undergoing PCI who are not at high bleeding risk (avoid in patients ≥75 years, <60 kg body weight, or history of stroke/TIA) 2, 3
  • Clopidogrel 75 mg daily is acceptable when ticagrelor or prasugrel are contraindicated 2

Statins

• High-intensity statin therapy must be initiated within 24 hours of ACS onset and continued indefinitely 1, 2, 4
• Pre-existing statin therapy should never be discontinued during hospitalization, as discontinuation increases short-term mortality 1, 4
• For intubated patients, statins can be crushed and administered via nasogastric/orogastric tube 4

Beta-Blockers

• Beta-blockers are indicated for all ACS patients unless contraindicated 1, 2
• Start at low doses once the patient is hemodynamically stable 1
• Continue for at least 3 years in patients with normal left ventricular ejection fraction (LVEF) 5
• Continue indefinitely if LVEF <40% 2, 5

ACE Inhibitors/ARBs

• ACE inhibitors should be prescribed and continued indefinitely for patients with heart failure, LVEF <0.40, hypertension, or diabetes 2
• ARBs are indicated for patients intolerant to ACE inhibitors who have heart failure or LVEF <0.40 2
• Insufficient evidence supports routine initiation in the ED, but should be started before discharge 1

Aldosterone Receptor Blockers

• Recommended for patients with LVEF ≤0.40 and either symptomatic heart failure or diabetes, provided they are already on therapeutic ACE inhibitor doses and have no significant renal dysfunction or hyperkalemia 2

Nitroglycerin

• Sublingual or spray nitroglycerin must be prescribed to all post-ACS patients with both verbal and written instructions 2
• Instruct patients to take one dose for angina lasting >1 minute, and call emergency services if not improved within 3-5 minutes 2

Cardiac Rehabilitation

Patients with ACS must be referred to an outpatient cardiac rehabilitation program prior to hospital discharge to reduce death, MI, hospital readmissions, and improve functional status and quality of life 1

• Exercise-based CR programs reduce risk of MI, all-cause hospitalization, and healthcare costs 1
• Home-based CR is a reasonable alternative to center-based CR for improving functional status and quality of life 1
• Hybrid models combining center- and home-based programs may offer additional benefits 1

Discharge Planning and Patient Education

Essential Components at Discharge (Table 21 Framework) 1

Communication:

• Provide patient-centered education both verbally and in writing in the patient's preferred language 1
• Use shared decision-making to discuss goals and preferences with patient/caregivers 1

Clinical Assessment:

• Address comorbidities and risk factors for recurrent events 1
• Assess for ongoing ischemic symptoms using standardized instruments embedded in the electronic health record 1
• Evaluate bleeding risk related to medications or procedural sites 1
• Perform comprehensive medication reconciliation 1
• Ensure influenza and other vaccinations are current 1

Patient/Caregiver Education Must Include: 1, 2

• Reason for hospitalization with explanation of diagnostic tests and procedural results 1
• Tailored discussion of lifestyle modifications (AHA's Life's Essential 8) 1
• Detailed medication instructions: purpose, dose, frequency, potential adverse effects, refill instructions, changes from pre-hospital regimen, and critical importance of adherence 1
• Symptom management: what to monitor and specific actions if symptoms recur, including emergency contact information 1
• Return to daily activities: when to resume physical activity, sexual activity, work, and travel 1
• Psychosocial considerations with open dialogue about depression and anxiety symptoms 1
• Follow-up care appointments with cardiology, CR, and any additional testing 1

Use teach-back method to confirm patient/caregiver understanding of self-care and medication adherence 1

Social Determinants of Health

• Assess and address barriers to obtaining prescribed medications, including referral to pharmacy assistance programs or social workers 1
• Assess and address barriers to attending CR, including viability of home-based or hybrid CR options 1

Post-Discharge Follow-Up

First follow-up appointment must occur within 6 weeks of discharge, as appointments scheduled beyond 6 weeks reduce medication adherence 5

• Hospital-initiated support interventions reduce mortality at 3 months and 1 year, and decrease 30-day readmission rates 1
• Care coordinator involvement is associated with lower readmission and mortality rates 5
• Approximately 1 in 5 patients are readmitted within 30 days; women, underrepresented racial/ethnic groups, and ICU patients are at highest risk 1

Duration of Antiplatelet Therapy Modifications

Standard Duration

• DAPT should be continued for at least 12 months in patients not at high bleeding risk 1

De-escalation Strategies (if bleeding risk is high)

• Transition to ticagrelor monotherapy ≥1 month post-PCI may reduce bleeding risk while maintaining efficacy 1
• De-escalation from ticagrelor or prasugrel to clopidogrel after 1 month may be reasonable to reduce bleeding 1
• Transition to single antiplatelet therapy after 1 month may be reasonable in high bleeding risk patients 1

Bleeding Risk Mitigation

• Proton pump inhibitor (PPI) is recommended in combination with DAPT for patients at high gastrointestinal bleeding risk 1

Common Pitfalls to Avoid

• Never discontinue DAPT prematurely, particularly in the first few weeks after ACS, as this dramatically increases risk of subsequent cardiovascular events 3
• Do not overlook beta-blockers or ACE inhibitors, as this results in missed mortality benefit 2
• Inadequate antiplatelet coverage significantly increases recurrent event risk 2
• Failing to provide nitroglycerin education is a common and dangerous oversight 2
• Do not discontinue statins during hospitalization, as this increases mortality and major adverse cardiac events 4
• Avoid unnecessary dose escalation when lipid targets are nearly achieved and therapy is well-tolerated 6
• Never skip CR referral before discharge, as only 67% of patients recall being referred and only 33% complete programs when referred 7
• Ensure discharge summary reaches primary care physician with medication list, chest pain action plan, and risk factor modification advice 7