Risk stratification
–Stress test if anatomy undefined or residual CAD
–Echocardiography to assess left ventricular ejection fraction
Cardiac catheterization with coronary angiography is advised for patients at high risk for
recurrent MI such as:
– Angina induced at relatively low workload
– Large reversible defect on perfusion imaging or a depressed ejection fraction
– Demonstrable ischemia
– Symptomatic ventricular arrhythmia provoked by exercise
Medications (unless contraindicated)
Remember the MONABASH mnemonic? While it is important for acute management of ACS, it is also great for long-term ACS Management.
Morphine – This likely won’t be needed at the time of discharge.
Oxygen – Not needed unless for some reason the patient is still hypoxemic.
Nitroglycerin SL for all patients. NTG 0.3-0.6 mg SL q5min; Max: 3 doses within 15 minutes.
Antiplatelets:
Antiplatelet therapy with aspirin AND a platelet P2Y12 receptor blocker is indicated in all patients with a non-ST elevation ACS unless there is an absolute contraindication.
-Aspirin 81 mg daily. ASA is to be taken for life (i.e. indefinitely) unless contraindicated.
-Clopidogrel / Prasugrel / ticagrelor (see treatment lengths here).
Beta-blocker
ACEI. Use for life if the patient has HF, reduced EF, HTN, or Diabetes. Use at least 4-6 weeks in all patients with STEMI.
Statin. High-intensity statin for all patients with ACS, regardless of how good their lipid panel may look. Atorvastatin 80mg po Qbedtime or Rosuvastatin 20-40 mg daily.
Heparin is usually not needed. However, oral anticoagulants (e.g. Warfarin or DOACs) may be needed in addition to ASA / clopidogrel e.g. when there is AF or LV thrombus.
Aldosterone antagonist if LVEF < 40% and either DM or s/s of HF.
ICD
See indications for ICD from ACC
Risk factors and lifestyle modification
Risk factors and lifestyle modification post ACS.
Patient education before discharge.
Provide patient education.
References
World Health Organization, http://www.searo.who.int/india/topics/cardiovascular_diseases/NCD_Resources_CLINICAL_MANAGEMENT_GUIDELINES_FOR_CAD.pdf?ua=1 Last Accessed 11/10/2017
http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/03/25/14/56/2016-acc-aha-guideline-focused-update-on-duration-of-dapt
ACC/AHA Guideline on Duration of Dual Antiplatelet Therapy in CAD Patients.