Revised ACS Guideline: Practice Points for Pharmacists

Managing patients with acute coronary syndrome (ACS) is a team project. If primary care physicians, nurse practitioners, and pharmacists are omitted from the team, then ACS patients are much less likely to receive the full range of intervention, rehabilitation, and education they need.

The American College of Cardiology and American Heart Association recently revised their guideline for the management of non ST-segment elevation ACS (NSTE-ACS) and ST-segment elevation myocardial infarction (STEMI), emphasizing antiplatelet therapy for both. An article published in the March-April 2015 issue of Heart & Lung summarizes the elements important to pharmacists.

The guideline recommends dual antiplatelet therapy comprising aspirin plus a P2Y₁₂ receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) for patients with NSTE-ACS and those with STEMI. It further advises treating patients during and after reperfusion.

There is a new recommendation to select ticagrelor over clopidogrel in patients managed by an ischemia-guided strategy or invasively treated patients, and prasugrel over clopidogrel in patients undergoing percutaneous coronary intervention (PCI). The underlying reason is data showing prasugrel and ticagrelor are more effective than clopidogrel when used in combination with aspirin in those with STEMI or NSTE-ACS patients undergoing PCI.

The review authors note clopidogrel has a longer clinical history than the other P2Y₁₂ inhibitors, leading to its endorsement in patients with STEMI who are receiving fibrinolytic therapy. It may also have a cost advantage attractive to un- or under-insured patients.

Clopidogrel is a prodrug that requires hepatic bioactivation. Even though the guideline doesn’t recommend routine CYP2D19 genetic polymorphism testing when clopidogrel is considered, the review authors advise it.

A crucial point for pharmacists to emphasize with patients—especially those who have stents—is that premature discontinuation of antiplatelet therapy is associated with poor outcomes. In fact, stent thrombosis is considerably more likely when patients stop antiplatelet therapy.

ACS patients require support and education about the benefits of long-term medication adherence. The authors conclude with an obvious recommendation for multidisciplinary team members who work with post-ACS patients to get familiar with the latest guideline.

To make that easier, this review provides a set of tables worthy of clipping. One in particular lists the guideline’s recommendations succinctly, while another provides a comprehensive comparison of the 3 available P2Y₁₂ inhibitors. Each inhibitor’s pivotal clinical studies provide evidence and support for use in specific patient populations (Table).