Secondary prevention after acute coronary syndrome — structured written assessment

Abbreviations

Short-answer question 1 (10 marks)

Scenario

A 68-year-old man had a drug-eluting stent placed for NSTE-ACS 3 days ago. He has no history of stroke or transient ischaemic attack, no indication for oral anticoagulation and no bleeding history. His haemoglobin and kidney function are normal. He is being prepared for discharge. (Practice scenario.)

Questions — question 1

1. State the 2023 ESC default antiplatelet regimen after PCI for ACS, with its duration, class and maintenance doses. (3)^[1]
2. List four ARC-HBR major criteria and state the HBR rule used by ACC/AHA 2025. (2)^[2]
3. Give three ESC 2023 Recommendation Table 6 options for shortening or de-escalating antiplatelet therapy, each with its condition and class. (3)^[1]
4. If he were also found to have atrial fibrillation needing oral anticoagulation during this admission, what does the 2025 ACC/AHA ACS guideline recommend for his antiplatelet therapy? (2)^[2]

Model answers — question 1

1. ESC 2023 recommends a P2Y12 receptor inhibitor in addition to aspirin in all ACS patients, as an initial oral loading dose followed by a maintenance dose for 12 months unless there is HBR (Class I, Level A).^[1] Aspirin is recommended for all patients without contraindications, with a maintenance dose of 75–100 mg once daily for long-term treatment (Class I, Level A).^[1] Prasugrel is recommended in P2Y12 receptor inhibitor-naïve patients proceeding to PCI, with a maintenance dose of 10 mg once daily, or 5 mg once daily if aged 75 years or more or weighing less than 60 kg (Class I, Level B); ticagrelor is recommended irrespective of treatment strategy, with a maintenance dose of 90 mg twice daily (Class I, Level B).^[1] Also creditable: prasugrel should be considered in preference to ticagrelor for ACS patients who proceed to PCI (Class IIa, Level B), and clopidogrel 75 mg once daily is recommended when prasugrel or ticagrelor are not available, cannot be tolerated or are contraindicated (Class I, Level C).^[1]
2. Any four ARC-HBR major criteria from ACC/AHA 2025 Table 22: anticipated long-term oral anticoagulation; severe or end-stage CKD (eGFR below 30 mL/min); haemoglobin below 11 g/dL; spontaneous bleeding requiring hospitalisation or transfusion in the past 6 months or at any time if recurrent; moderate or severe baseline thrombocytopenia (platelets below 100 × 10⁹/L); chronic bleeding diathesis; liver cirrhosis with portal hypertension; active malignancy (excluding nonmelanoma skin cancer) within the past 12 months; previous spontaneous intracranial haemorrhage, traumatic intracranial haemorrhage within 12 months, brain arteriovenous malformation, or moderate or severe ischaemic stroke within 6 months; nondeferrable major surgery on DAPT; recent major surgery or major trauma within 30 days before PCI.^[2] Rule: the presence of at least 1 major or 2 minor criteria helps to identify those at increased risk of bleeding.^[2] Cross-guideline context (no marks for this ACC/AHA question): ESC 2023 says HBR should be assessed in a structured manner, for example a single major or two minor characteristics as defined by ARC-HBR.^[1]
3. SAPT after 3–6 months: in patients who are event-free after 3–6 months of DAPT and who are not high ischaemic risk, single antiplatelet therapy (preferably with a P2Y12 receptor inhibitor) should be considered (Class IIa, Level A).^[1] De-escalation: de-escalation of P2Y12 receptor inhibitor treatment (for example a switch from prasugrel or ticagrelor to clopidogrel) may be considered as an alternative DAPT strategy to reduce bleeding risk (Class IIb, Level A).^[1] HBR: in HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered (Class IIb, Level B).^[1] Also creditable as the fourth row of the group: de-escalation of antiplatelet therapy in the first 30 days after an ACS event is not recommended (Class III, Level B).^[1]
4. ACC/AHA 2025: in patients with ACS who require oral anticoagulant therapy, aspirin should be discontinued after 1 to 4 weeks of triple antithrombotic therapy, with continued use of a P2Y12 inhibitor (preferably clopidogrel) and an oral anticoagulant to reduce bleeding risk (COR 1, LOE B-R).^[2] Also creditable: ACC/AHA 2025 says a DOAC will be preferred over a vitamin K antagonist for most patients, and that clopidogrel is generally favoured because trials of prasugrel and ticagrelor excluded patients requiring long-term anticoagulation.^[2]

Short-answer question 2 (10 marks)

Scenario

A 61-year-old woman with type 2 diabetes is recovering from NSTE-ACS treated with PCI. She has never taken a statin or any other lipid-lowering therapy. Her LDL-C on admission is 3.4 mmol/L, her pre-discharge LVEF is 38%, and she has no symptoms of heart failure. (Practice scenario.)

Questions — question 2

1. State the 2023 ESC LDL-C goal and the stepwise lipid-lowering rows that follow statin therapy, with their timing and classes. (3)^[1]
2. What does the 2025 ESC/EAS focused update recommend about statin plus ezetimibe during the index admission, and when would it apply to her? (2)^[3]
3. Which ESC 2023 Recommendation Table 16 cardioprotective drug rows apply to her, given her LVEF and diabetes? (3)^[1]
4. What follow-up imaging does ESC 2023 recommend for her, and why? (2)^[1]

Model answers — question 2

1. ESC 2023 recommends aiming for LDL-C below 1.4 mmol/L (below 55 mg/dL) and a reduction of 50% or more from baseline (Class I, Level A), with high-dose statin initiated as early as possible regardless of initial LDL-C (Class I, Level A).^[1] If the goal is not achieved despite maximally tolerated statin therapy after 4–6 weeks, adding ezetimibe is recommended (Class I, Level B); if still not achieved despite maximally tolerated statin and ezetimibe after 4–6 weeks, adding a PCSK9 inhibitor is recommended (Class I, Level A).^[1] Also creditable: combination therapy with high-dose statin plus ezetimibe may be considered during index hospitalisation (Class IIb, Level B).^[1]
2. ESC/EAS 2025: initiating combination therapy with high-intensity statin plus ezetimibe during index hospitalisation for ACS should be considered in patients who were treatment-naïve and are not expected to achieve the LDL-C goal with statin therapy alone (Class IIa, Level B).^[3] She is treatment-naïve, so it would apply if her clinicians judge that she is not expected to reach the goal with statin therapy alone; the update notes that the extent of LDL-C reduction in response to pharmacological interventions is predictable based on baseline LDL-C levels.^[3]
3. Beta-blockers are recommended in ACS patients with LVEF 40% or less regardless of HF symptoms (Class I, Level A).^[1] ACE inhibitors are recommended in ACS patients with HF symptoms, LVEF 40% or less, diabetes, hypertension and/or CKD (Class I, Level A), with angiotensin receptor blockers in cases of intolerance; she qualifies through LVEF and diabetes.^[1] Mineralocorticoid receptor antagonists are recommended in ACS patients with an LVEF of 40% or less and HF or diabetes (Class I, Level A); she qualifies through LVEF 38% and diabetes.^[1] Cross-guideline context (no marks for this ESC question): ACC/AHA 2025 says that in patients with ACS and LVEF 40% or less, and with HF symptoms and/or diabetes mellitus, a mineralocorticoid receptor antagonist is indicated to reduce all-cause death and MACE (COR 1, LOE B-R); its supporting text adds that it should be given in the absence of advanced CKD, hyperkalaemia or other contraindication.^[2]
4. ESC 2023: with a pre-discharge LVEF of 40% or less, repeat LVEF evaluation 6–12 weeks after the ACS (and after complete revascularisation and the institution of optimal medical therapy) is recommended to assess the potential need for primary prevention ICD implantation (Class I, Level C).^[1] Also creditable: cardiac magnetic resonance imaging should be considered as an adjunctive imaging modality to assess the potential need for primary prevention ICD implantation (Class IIa, Level C).^[1]