New guidance issued on acute coronary syndromes
The updated recommendations from the American College of Cardiology, the American Heart Association, and other professional societies focus on management of unstable angina and myocardial infarction.
Dual antiplatelet therapy (DAPT) with aspirin and an oral P2Y12 inhibitor is indicated for at least 12 months in patients with acute coronary syndrome (ACS) who are not at high bleeding risk, according to an updated guideline.
This and other recommendations on management of ACS were developed by the American College of Cardiology, the American Heart Association, the American College of Emergency Physicians, the National Association of EMS Physicians, and the Society for Cardiovascular Angiography & Interventions. They were published Feb. 27 by JACC and Circulation.
Strategies to reduce bleeding risk in patients taking DAPT include prescribing a proton-pump inhibitor to those prone to gastrointestinal bleeding, the guideline noted. In addition, patients who have tolerated DAPT with ticagrelor can be transitioned to ticagrelor monotherapy at least one month after percutaneous coronary intervention (PCI), and in patients who require long-term anticoagulation, aspirin discontinuation is recommended one to four weeks after PCI (use of a P2Y12 inhibitor, preferably clopidogrel, should be continued).
Physicians should order a fasting lipid panel in patients with ACS four to eight weeks after lipid-lowering therapy has been started or after the dose has been adjusted in order to gauge response or determine whether additional medications are needed, the guideline said. People with ACS who are taking a maximally tolerated statin and have a low-density lipoprotein (LDL) cholesterol level greater than or equal to 70 mg/dL should add a concurrent nonstatin lipid-lowering agent, such as ezetimibe, evolocumab, alirocumab, inclisiran, or bempedoic acid, to further decrease risk, according to the guideline. Adding a nonstatin to reduce risk is also considered reasonable in patients with LDL cholesterol levels of 55 to 69 mg/dL who are already taking a maximally tolerated statin, the guideline said. It also noted that low-dose colchicine may be reasonable after ACS to reduce risk of major adverse cardiovascular events.
Patients with ACS should be referred to outpatient cardiac rehab before hospital discharge in order to reduce risk for death, myocardial infarction (MI), and readmission and improve functional status and quality of life, according to the guideline.
The guideline authors noted that one of the most important research gaps in ACS management is the timeline for the transition from ACS to chronic coronary syndrome and how to manage antiplatelet and other therapies once this transition is completed. In addition, regarding long-term secondary prevention, the authors said that more research is needed on home-based versus facility-based cardiac rehab, the role of glucose-like peptide-1 receptor agonists after MI, and use of high-dose aspirin in patients with post-MI pericarditis, among other topics.