Optimising pharmacotherapy for secondary prevention of non-invasively managed acute coronary syndrome.
About half of all patients who experience an acute coronary syndrome (ACS) in Australia have their conditions managed non-invasively - that is, they do not undergo coronary angiography and revascularisation in hospital. ACS patients whose conditions are managed non-invasively may not receive the same level of evidence-based care as those who receive coronary revascularisation. This article reviews the optimal pharmacological management of ACS managed non-invasively. There is strong evidence to support the prescription of dual antiplatelet therapy (DAPT; aspirin with a P2Y12 inhibitor). DAPT should continue for 12 months after an ACS, then aspirin should be continued indefinitely. Anticoagulation with warfarin or a novel oral anticoagulant may be needed if atrial fibrillation occurs; the combination with DAPT increases the risk of bleeding. Unless contraindicated, high-intensity statin therapy should be prescribed for all post-ACS patients irrespective of their cholesterol level. Non-statin lipid therapy has not been shown to improve outcomes. Use of β-adrenergic blockers is recommended in most guidelines, but the clinical trials to support this recommendation were performed more than 30 years ago, and routine long-term use may not be relevant to modern treatment, except when there is cardiac failure or left ventricular dysfunction. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are also widely recommended, but the evidence for benefit is stronger when there is left ventricular dysfunction. Calcium-channel blockers, nitrates, antiarrhythmic drugs, digoxin and diuretics do not improve outcomes in post-ACS patients.
School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia. peterlthompson@health.wa.gov.au.
Peter L
PL
Thompson
Sir Charles Gairdner Hospital, Perth, WA, Australia.
Angus G
AG
Thompson
Fremantle Hospital, Perth, WA, Australia.
Chris
C
Judkins
D054058:Acute Coronary Syndrome / Q000150:complications / Q000188:drug therapy* / Q000517:prevention & control*; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000924:Anticholesteremic Agents / Q000008:administration & dosage; D001241:Aspirin / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000517:prevention & control; D000077144:Clopidogrel; D003328:Coronary Thrombosis / Q000150:complications / Q000517:prevention & control; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage; D055502:Secondary Prevention; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000924:Anticholesteremic Agents; D005343:Fibrinolytic Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin