Secondary prevention after non-ST-elevation acute coronary syndrome with high bleeding risk — case discussion

Abbreviations

Case presentation

A 72-year-old man is recovering from NSTE-ACS treated with a drug-eluting stent. He has hypertension and dyspepsia. His eGFR is 50 mL/min and his haemoglobin 12.5 g/dL. He has no history of bleeding, stroke, cancer or anticoagulant use, and he has never taken a statin or any other lipid-lowering therapy. His LDL-C on admission is 2.9 mmol/L and his pre-discharge LVEF is 50%. (Practice case; not a real patient.)

Step 1 — Is he at high bleeding risk?

Discussion:

• Under the ARC-HBR criteria in ACC/AHA 2025 Table 22, moderate CKD (eGFR 30–59 mL/min) is a minor criterion, and haemoglobin 11–12.9 g/dL in a man is a minor criterion; age 75 years or more would also be minor, but he is 72.^[2]
• The presence of at least 1 major or 2 minor criteria helps to identify those at increased risk of bleeding, so with two minor criteria he meets that rule.^[2]
• ESC 2023 asks for structured HBR assessment, for example a single major or two minor ARC-HBR characteristics.^[1]

Step 2 — Antiplatelet plan

Discussion:

• ESC 2023 recommends a P2Y12 receptor inhibitor in addition to aspirin for 12 months unless there is HBR (Class I, Level A); he has HBR, and ESC 2023 says shortened or de-escalated strategies should only be used as alternatives to 12-month DAPT, in general driven by a motivation to reduce bleeding risk (for example, if the patient is HBR).^[1]
• ESC 2023: in HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered (Class IIb, Level B); de-escalation in the first 30 days is not recommended (Class III, Level B).^[1]
• ACC/AHA 2025: in patients with ACS undergoing PCI who are at high bleeding risk, transition to SAPT (aspirin or a P2Y12 inhibitor) after 1 month may be reasonable to reduce bleeding risk (COR 2b, LOE B-R).^[2]
• NHFA/CSANZ 2025: in people at low ischaemic and/or high bleeding risk, cease DAPT at 1–3 months and continue SAPT (strong recommendation, high certainty).^[5]
• Gastric protection: ESC 2023 Table 7 (suggested strategies to reduce bleeding risk related to PCI) lists proton pump inhibitors in patients on DAPT at higher-than-average risk of gastrointestinal bleeds, meaning a history of gastrointestinal ulcer or haemorrhage, anticoagulant therapy or chronic non-steroidal anti-inflammatory drug or corticosteroid use, or two or more of: age 65 years or more, dyspepsia, gastro-oesophageal reflux disease, Helicobacter pylori infection and chronic alcohol use; he is 72 with dyspepsia.^[1]

Step 3 — Lipids

Discussion:

• ESC 2023 recommends initiating high-dose statin therapy as early as possible, regardless of initial LDL-C (Class I, Level A), and aiming for LDL-C below 1.4 mmol/L with a reduction of 50% or more from baseline (Class I, Level A).^[1]
• ESC/EAS 2025: initiating combination therapy with high-intensity statin plus ezetimibe during index hospitalisation should be considered in patients who were treatment-naïve, as he is, and are not expected to achieve the LDL-C goal with statin therapy alone (Class IIa, Level B).^[3]
• ESC 2023 says lipid levels should be re-evaluated 4–6 weeks after each treatment or dose adjustment; ACC/AHA 2025 recommends a fasting lipid panel 4 to 8 weeks after initiation or dose adjustment of lipid-lowering therapy to assess response or adherence (COR 1, LOE C-LD).^[1][2]

Step 4 — Cardioprotective drugs

Discussion:

• His LVEF of 50% is above 40%, so the ESC 2023 Class I beta-blocker row (LVEF 40% or less) does not apply; ESC 2023 says routine beta-blockers for all ACS patients regardless of LVEF should be considered (Class IIa, Level B).^[1]
• NHFA/CSANZ 2025, by contrast, says to consider withholding beta-blockers in people with ACS and preserved LV systolic function who have undergone coronary revascularisation and are receiving optimal medical therapy (weak recommendation, moderate certainty).^[5]
• ESC 2023 recommends ACE inhibitors in ACS patients with hypertension (among other conditions) (Class I, Level A), with angiotensin receptor blockers in cases of intolerance.^[1]
• ACC/AHA 2025 counts hypertension as high risk: an oral ACE inhibitor or angiotensin receptor blocker is indicated to reduce all-cause death and MACE (COR 1, LOE A).^[2]
• ESC 2023 also recommends adapting the choice and dosage of secondary prevention drugs in older patients to renal function, co-medications, comorbidities, frailty, cognitive function and specific contraindications (Class I, Level B).^[1]

Step 5 — Rehabilitation, lifestyle and vaccination

Discussion:

• Patients with ACS should be referred to an outpatient CR program before hospital discharge to reduce death, MI and hospital readmissions and to improve functional status and quality of life (ACC/AHA 2025, COR 1, LOE A); after ACS, CR should ideally begin in the first 14 days and no later than 30 days (ESC 2026).^[2][4]
• CR is not recommended to be withheld from patients with an indication for CR because of frailty or comorbidities (ESC 2026, Class III, Level C).^[4]
• Influenza vaccination is recommended for all ACS patients (ESC 2023, Class I, Level A), preferentially during the index hospitalisation in influenza season if he is not protected by a seasonal vaccination.^[1]

Step 6 — Follow-up

Discussion:

• His pre-discharge LVEF is above 40%, so the ESC 2023 row for repeat LVEF at 6–12 weeks (pre-discharge LVEF 40% or less) does not apply to him.^[1]
• ESC 2023 Figure 17 lists an outpatient review to manage comorbidities and discuss patient goals and preferences, with a BP target of systolic below 130 mmHg and diastolic below 80 mmHg if tolerated (for patients aged 70 years or more, systolic below 140 mmHg and down to 130 mmHg if tolerated).^[1]