Principles of long-term management of acute coronary syndromes

Base long-term management of an acute coronary syndrome on the clinical course and the findings at coronary angiography (if performed). Following an acute coronary syndrome, most patients benefit from long-term combination therapy with antiplatelet therapy, a statin, an angiotensin converting enzyme inhibitor (ACEI) (or angiotensin II receptor blocker [ARB]) and a beta blocker. Oral anticoagulation may also be needed for patients with complications associated with myocardial infarction, such as mural thrombus or atrial fibrillation. Most drugs for long-term management of an acute coronary syndrome are either used for a set duration or are continued indefinitely; for typical duration of drug therapy, see Typical duration of drug therapy following an acute coronary syndrome.

Other drugs used in specific patient groups are mineralocorticoid receptor antagonists, calcium channel blockers, colchicine, antihyperglycaemic drugs and low-intensity rivaroxaban therapy.

Table 1. Typical duration of drug therapy following an acute coronary syndrome
Drug therapy		Typical treatment duration
antithrombotic therapy (dual or triple therapy)	dual antiplatelet therapy (aspirin plus P2Y₁₂ inhibitor)	use for 12 months at 12 months, P2Y₁₂ inhibitor is usually stopped and aspirin is continued alone [NB2] occasionally, long-term therapy with aspirin plus low-intensity rivaroxaban therapy is used; see Antiplatelet and anticoagulant drugs for secondary prevention of atherosclerotic cardiovascular events
	triple antithrombotic therapy (aspirin plus P2Y₁₂ inhibitor plus anticoagulant) [NB1]	usually 1 to 4 weeks of triple antithrombotic therapy, followed by dual antithrombotic therapy (one antiplatelet plus the anticoagulant) at 12 months, antiplatelet therapy is usually stopped, and the oral anticoagulant continued alone
statin therapy		continue indefinitely in all patients
ACEI or ARB therapy		continue indefinitely in all patients
beta-blocker therapy		use for 12 months in all patients at 12 months, review ongoing need; benefit of continued treatment is greatest in patients with ongoing ischaemia, heart failure or left ventricular dysfunction
Note: ACEI = angiotensin converting enzyme inhibitors; ARB = angiotensin II receptor blockers NB1: Triple therapy is only used following an acute coronary syndrome in patients with an indication for oral anticoagulation (eg atrial fibrillation). NB2: In select cases, or if aspirin is contraindicated, indefinite therapy with a P2Y₁₂ inhibitor alone may be used.

Following an acute coronary syndrome, patients should also be prescribed a glyceryl trinitrate spray or tablet for as-needed relief of angina-associated pain; see Treatment of episodes of angina for more information.

Educate patients about cardioprotective and risk factor–modifying drugs, and about adopting a healthy lifestyle (eg quitting smoking, being physically active, healthy eating) to reduce the risk of recurrent cardiovascular events. For more information, see Modifiable lifestyle risk factors for atherosclerotic cardiovascular disease. Consider referral to a cardiac rehabilitation program for all patients following an acute coronary syndrome.