Module 1870

Clinical

Module 1870 Aftercare for patients with acute coronary syndromes From this CPD module on preventing acute coronary syndromes you will learn about: • The long-term strategies to prevent acute coronary syndromes • Different medicines used in the management of unstable angina, NSTEMI and STEMI • The role of the pharmacist in the prevention of these conditions • Some of the concerns patients may have about their condition and how you can help

NAIMAH CALLACHAND, PHARMACIST Cardiovascular disease continues to be one of the leading causes of death in the developed world. However, the implementation of prevention measures has contributed to significantly reduced mortality rates and ischaemic event reoccurrence. Acute coronary syndromes (ACS) are a spectrum of clinical presentations, including ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) – see Update Module 1869 Acute coronary syndromes at tinyurl.com/acutecoronaryCD for more information. ACS is typically associated with rupture of an atherosclerotic plaque with partial or complete thrombosis of the artery, resulting in myocardial necrosis. Following a cardiac event, a patient will undergo reperfusion strategies and drug treatment to provide supportive care and pain relief, as well as to prevent further problems and death. Studies have shown that most recurrent cardiac events occur within the first year of an ACS. Secondary prevention strategies (those

be initiated as soon as the patient is clinically stable – typically defined as displaying normal vital signs, such as heart rate, systolic blood pressure, respiratory rate, oxygen saturation, and temperature. The dose will often require titration to a maximum tolerated or target dose, and this will be included in the patient’s discharge summary from hospital. Beta-blockers are often continued for at least 12 months post-MI in patients without left ventricular systolic dysfunction or heart failure – individuals with these conditions may need to continue a beta-blocker indefinitely or require specific management for heart failure. Cardioselective beta-blockers, such as metoprolol or atenolol, are often used. Beta-

blockers are often initiated at the lowest dose and titrated up to the maximum tolerated dose. Statins Statins reduce low-density lipoprotein (LDL) cholesterol levels in the blood, which results in plaque stabilisation and restoration of endothelial function. Statins are usually continued indefinitely post-MI. Examples include atorvastatin, simvastatin, pravastatin, fluvastatin and rosuvastatin. Anti-platelet therapy After an ACS event, activated platelets and thrombin can persist for long periods of time. This increases the risk of further ischaemic events and

performed after initial management) and treatment adherence will significantly reduce the risk of further ischaemic events.

Long-term pharmacological management Long-term management of ACS involves the use of a wide range of medicines, alongside behavioural changes, which are typically initiated before the patient is discharged from hospital. Provided there are no contraindications, all patients should be discharged from hospital following a myocardial infarction (MI) with a treatment plan consisting of: • a beta-blocker • a statin • antiplatelet therapy. An angiotensin-converting enzyme (ACE) inhibitor should also be considered, especially in patients with left ventricular dysfunction. Treatment should be tailored for each patient, based on their symptoms and clinical needs. Beta-blockers Beta-blockers lower the heart rate, reduce blood pressure and contractility (inherent strength and vigour of the heart’s contraction). They should

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Module 1870 | Acute coronary syndromes aftercare | 1 of 4

is therefore a therapeutic target for secondary preventive strategies. Aspirin 75mg daily reduces the risk of serious vascular events in patients at increased risk, including those with prior or acute events. The addition of a second antiplatelet, such as clopidogrel, to aspirin therapy has been shown to provide additional therapeutic benefit. Aspirin should be continued indefinitely, whereas other antiplatelet therapy – such as clopidogrel, prasugrel and ticagrelor – should be given for a minimum of 12 months after an ACS event. For those intolerant to antiplatelet therapy, who are at low risk of bleeding, warfarin sodium in combination with aspirin should be considered. Warfarin sodium can also be used

alone if aspirin is contraindicated. However, it is important to be aware that the combination of aspirin or clopidogrel with warfarin increases the risk of bleeding. Low-dose rivaroxaban, in combination with aspirin alone, or aspirin with clopidogrel, is licensed for the prevention of atherothrombotic events following a STEMI. Side effects of antiplatelet therapy can include gastrointestinal disturbances and, in the case of aspirin, bronchospasm. A proton pump inhibitor can be prescribed for patients experiencing gastrointestinal disturbances, in order to minimise symptoms. Calcium channel blockers Patients are not routinely offered calcium

channel blockers to reduce cardiovascular risk after an MI. However, the calcium channel blockers diltiazem or verapamil can be considered in patients without pulmonary congestion or left ventricular systolic dysfunction, to reduce blood pressure and contractility if beta-blockers are not tolerated. Calcium channel blockers do not reduce the risk of MI in UA, but can help prevent the symptoms of angina. ACE inhibitors and angiotensin receptor blockers ACE inhibitors and angiotensin receptor blockers (ARBs) reduce ventricular remodelling and prevent further deterioration in patients with reduced left ventricular function following an MI. These medicines should not be given in combination; rather, the most suitable option should be used. For example, patients who have suffered an MI and who are intolerant to ACE inhibitors should be offered an ARB. This treatment is usually continued indefinitely. There may be a need to titrate the dose upwards at short intervals before the patient leaves hospital, until the maximum tolerated or target dose is reached. If it is not possible to complete the titration during this time, it should be completed within four to six weeks after discharge. Patients may have their renal function, serum electrolytes and blood pressure checked as they have their dose adjusted, and at least once a year thereafter.

Further management strategies

Aspirin 75mg daily reduces the risk of serious vascular events in those with a history of ACS


The management of underlying disorders such as hypertension, diabetes and other risk factors – whether through pharmacological intervention or lifestyle changes – is an important aspect of secondary prevention. Aldosterone antagonists, such as eplerenone, can be initiated in patients with signs or symptoms of heart failure or those with left

ventricular dysfunction, within 14 days of an MI, usually following ACE inhibitor therapy. Potassium levels and renal function should be monitored during therapy with aldosterone antagonists.

Additional treatments for NSTEMI and UA The pharmacological interventions for NSTEMI and UA are broadly similar. The need for long-term angina treatment or coronary angiography should be assessed, with most patients requiring angina treatment to prevent recurrence of symptoms. Patients at high risk of further ACS should be considered for an angiogram – an imaging technique used to visualize the inside of a blood vessel – alongside percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) if required. For more information on these procedures, see Update module 1869 Acute coronary syndromes at tinyurl.com/acutecoronaryCD. Nitrates Nitrates improve blood flow by dilating and relaxing the arteries. This improves oxygen supply to the heart muscle, helping prevent the symptoms of angina. Nitrates can be taken sublingually (such as glyceryl trinitrate spray) to treat symptoms of angina when engaging in strenuous activities (for example, walking uphill or playing sports). Sublingual glyceryl trinitrate takes effect within two to five minutes and the effects can last up to 30 minutes. An additional two doses, five minutes apart, can be taken if symptoms persist. However, patients should seek immediate medical attention if symptoms are not resolved after these additional doses. Side effects of nitrates can include headache, light-headedness, flushing and an increase in heart rate. Elderly patients are more sensitive to the effects of nitrates and are more likely to experience dizziness or light-headedness. You


can advise patients to sit down when taking fast-acting nitrates, to help avoid these side effects. Oral nitrates, such as isosorbide mononitrate, can be prescribed once daily. If nitrates are taken regularly then they remain in the bloodstream and the body becomes tolerant. This means the nitrate will have much less of an effect – known as nitrate tolerance. Spacing the dosing and using modified-release preparations can help avoid this.

Cardiac rehabilitation All patients – regardless of age – who have experienced ACS should be provided with advice about cardiac rehabilitation. This is a programme of exercise and information to ensure the individual can return to normal activities after their ACS treatment. The prescriber will need to establish the individual’s circumstances before offering lifestyle advice and encouraging attendance to a cardiac rehabilitation programme. Rehabilitation can be conducted in hospital, the community or in the patient’s home. Patients can find the location of their nearest cardiac rehabilitation programme by visiting www.cardiacrehabilitation.net or calling the Heart Helpline on 0300 330 3311.

What can the pharmacist do? Spending some time with the patient to explain their medication regimen and answer questions can reduce any anxiety about the plethora of medicines they may have been prescribed. It can also help improve adherence. Many of the medicines used to treat ACS will have a broad range of side effects. It is not necessary to inform patients of all of these. However, you should explain some side effects – such as muscle pain with statin use – as the patient will need to report them to the prescriber if they occur. You should use your clinical judgement to determine what side effects are likely to occur and whether a patient

requires additional warnings or information. With some medicines, the side effects may occur for a limited duration – eg postural hypotension with ACE inhibitor use – and tend to resolve with time. Others – such as the cough associated with taking an ACE inhibitor – may persist and warrant re-evaluation of the medicine choice by the prescriber. In England, patients with ACS typically fall into the target medicines use review (MUR) group of ‘patients at risk of or diagnosed with cardiovascular disease and regularly being prescribed at least four medicines’. They should therefore be considered for an MUR – whether this is post-discharge or after they have been taking their medication for a prolonged period.

undertake smoking cessation – either through their pharmacy or GP. Throughout smoking cessation, is it important to have regular followups with the patient to encourage and support them and to ensure treatment adherence.

• eat at least two portions of fish per week,

Cardioprotective diet By encouraging patients to have a cardioprotective diet, you can reduce the risk of hypertension and high cholesterol. You should encourage patients to: • eat at least five portions of fruit and vegetables per day

fat) in their diet – so total fat intake is 30% or less of total energy intake • minimise consumption of foods containing refined sugars • drink between six to eight glasses of water per day.

including a portion of oily fish

• eat high-fibre foods, such as wholewheat pasta or brown rice

• keep salt intake low (less than 6g per day) • reduce the amount of fat (especially saturated

What are the risk factors for ACS? ACS are much more common in patients with the following risk factors: • smoking • high blood pressure • high cholesterol • diabetes • physical inactivity • being obese or overweight • family history of ACS • being elderly. Working in the pharmacy means you are perfectly placed to help advise patients on lifestyle changes they can make to prevent further ACS. Smoking Smoking is a well-known risk factor for cardiovascular disease and many prevention guidelines stress the importance of smoking cessation. Smoking causes an increase in endothelial damage and dysfunction, oxidative stress, and is associated with higher levels of serum cholesterol. Smoking therefore significantly increases the risk of atherosclerosis, which can ultimately result in ACS. Pharmacists can advise patients to


Smoking significantly increases the risk of atherosclerosis, which can ultimately result in ACS


Exercise You should advise patients to be physically active and avoid prolonged periods of inactivity. The NHS recommends a minimum of 150 minutes of moderate-intensity aerobic activity per week – this can include brisk walking and cycling. For patients with low levels of physical activity, you can encourage them to make small changes to their day, such as walking to work, taking stairs rather than the lift, or going for a brisk walk during their lunch break. Weight management For patients who are overweight or obese, following a balanced healthy diet combined with increased exercise can help to significantly reduce their risk of mortality. You can support

patients throughout their weight loss journey and, if appropriate, offer regular weighing sessions in the pharmacy, where you can offer advice. If diet and exercise are not producing suitable weight loss, the patient can be referred to their GP for pharmacological or psychological intervention, such a cognitivebehavioural therapy. However, pharmacological interventions should not be first-line in weight management. Alcohol consumption The NHS recommends a maximum alcohol intake for both men and women of 14 units per week, spread over three or more days. You should advise patients to have at least two alcohol-free days per week and to

Acute coronary syndromes aftercare CPD Reflect For how long after an ACS event should antiplatelet therapy with clopidogrel be continued? What are the side effects of sublingual nitrates? What is a cardioprotective diet? Plan This article contains information about long-term strategies to prevent ACS and the medicines used in the management of UA, NSTEMI and STEMI. The role of the pharmacist in the prevention of ACS and some of the concerns patients may have about the condition are also discussed. Act

• Read more about secondary prevention of MI on the Clinical Knowledge Summaries (CKS) website at tinyurl.com/acutecs5

• Read more about cardiac rehabilitation on the Patient website at tinyurl.com/acutecs6 • Find out more about cardioprotective diets from the patient leaflet produced by Queen Elizabeth Hospital Birmingham at tinyurl.com/acutecs7 • Identify any patients who might benefit from a patient consultation or MUR • Read C+D’s Update Module 1869 Acute coronary syndromes, if you have not already done so Evaluate Are you now confident in your knowledge of the prevention strategies for ACS? Could you give advice to patients about the medicines used in ACS management and how to reduce their risk factors for the condition?


avoid binge drinking.

What other concerns may a patient have? Following an MI, most patients are able to return to work and normal daily activities. When and how they do this is dependent on the person’s physical and psychological status, as well as the nature of the work or activity. You should refer patients who drive to the Driver and Vehicle Licensing Agency website for recommended driving restrictions after an MI, and encourage them to check whether they are still covered by their insurer. You should also advise patients that sexual activity does not increase the risk of a secondary event and can be resumed when comfortable for the patient – typically four

weeks after the event. Patients may also suffer stress and anxiety following an MI and may benefit from psychological support. If you suspect a patient is not coping well post-MI, they should be referred to their GP for further support. If a patient is considering air travel or competing in competitive sports following their MI, they will need to seek advice from their cardiologist – as some circumstances exist that would warrant caution (find more information at tinyurl.com/CDairtravel). Patients who have suffered from ACS are at greater risk of the complications of influenza. You should encourage these patients to receive their annual influenza vaccination either through the pharmacy, if you provide the service, or with their local GP.

Take the 5-minute test online 1. Studies have shown that most recurrent cardiac events occur within the first year of an ACS. True or false 2. After an MI, all patients should be discharged from hospital with a betablocker, a statin and antiplatelet therapy, unless contraindicated. True or false 3. Beta-blockers are initiated at the lowest dose and titrated up to the maximum tolerated dose. True or false 4. Statins act by reducing high-density lipoprotein (HDL) cholesterol levels in the blood. True or false 5. Antiplatelet therapy, such as clopidogrel, should be given for a minimum of 24 months after an ACS event. True or false

6. Novel oral anticoagulants, such as rivaroxaban, are not licensed for use in the prevention of atherothrombotic events in ACS. True or false 7. The effects of sublingual glyceryl trinitrate can last up to 60 minutes. True or false 8. Side effects of nitrates include headache, light-headedness, flushing and an increase in heart rate. True or false 9. A cardioprotective diet is low in saturated fat, with total fat intake comprising 30% or less of total energy intake. True or false 10. Patients who have suffered from ACS should receive an annual influenza vaccine. True or false
