Clinical management of Acute Coronary Syndrome in Usa

After ACS hospitalization

Schedule early follow-up visit to reassess lipid levels and adjust lipid-lowering therapy to achieve LDL-C targets.

If patient experiences adverse effects from statin

Consider rechallenge at each visit or switch to a different statin or class of lipid-lowering therapy. Statin intolerance requires exposure to at least 2 different statins with 1 at lowest available dose.

If LDL-C is very low

Do not downtitrate lipid-lowering therapy; very low LDL-C is associated with lowest risk of MACE without safety concern.

Before prescribing new lipid-lowering therapy

Verify and discuss out-of-pocket costs with patient.

At follow-up visits

Educate patient about importance of lipid-lowering therapies and address barriers to adherence.

In patients with ACS and type 2 diabetes or HF (regardless of diabetes status)

Initiate SGLT-2 inhibitor or GLP-1 receptor agonist at discharge if indicated.

If patient is on SGLT-2 inhibitor and scheduled for surgery (including CABG)

Stop canagliflozin, dapagliflozin, empagliflozin ≥3 days and ertugliflozin ≥4 days prior to surgery.

In patients with ACS without contraindications

Consider initiating low-dose colchicine (0.5 mg or 0.6 mg daily) for secondary prevention.

If colchicine is considered, check for contraindications

Do not use in patients with blood dyscrasias, renal failure (CrCl <15 mL/min), severe hepatic impairment, or concomitant P-glycoprotein/strong CYP3A4 inhibitors.

In patients after ACS without contraindication

Administer influenza vaccine before discharge or at first follow-up.

For all patients after ACS

Follow CDC immunization schedules for other vaccines (e.g., COVID-19, pneumococcal) as indicated.