Medication Talk
An official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources.
Listen in as we discuss current topics impacting medication therapy and patient care.
TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
Medication Talk
Meds After Acute Coronary Syndrome
Listen in as our expert panel discusses the latest recommendations for managing medications after heart attacks and other cardiac events. You’ll hear our panelists review which antiplatelets to use, the optimal blood pressure meds, and the role of statin and non-statin cholesterol meds.
Special guests:
- Danielle Blais, PharmD, FCCP, BCCP, BCPS
- Cardiology Lead Specialty Practice Pharmacist
- Richard M. Ross Heart Hospital
- The Ohio State University Wexner Medical Center
- Joel C. Marrs, PharmD, MPH., BCACP, BCCP, BCPS, FAHA, FASHP, FCCP, FNLA
- Professor and Coordinator of Clinical Outreach
- The University of Tennessee Health Science Center
- Department of Clinical Pharmacy & Translational Science
You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:
- Andrea Darby-Stewart, MD
- Associate Director, Honor Health Family Medicine Residency Program
- Clinical Professor of Family, Community & Occupational Medicine
- The University of Arizona College of Medicine – Phoenix
- Craig D. Williams, PharmD, FNLA, BCPS
- Clinical Professor of Pharmacy Practice
- Oregon Health and Science University
None of the speakers have anything to disclose.
This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in July 2025.
TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
The clinical resources mentioned are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- Dual Antiplatelet Therapy for Coronary Artery Disease
- Comparison of Oral Beta-Blockers
- Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors
- Cholesterol Guidelines (United States)
- Non-Statin Lipid-Lowering Agents
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This transcript is automatically generated.
00:00:07 Danielle Blais
So there was a point in the guidelines where if the LDL was less than 40, we would cut the statin dose in half. And then we kind of reversed course on that and really want to try and drive that LDL cholesterol as low as possible.
00:00:22 Danielle Blais
So I do try and explain to my patients because they sometimes will see numbers in the 20s and 30s with their LDL.
00:00:28 Danielle Blais
Well, that that number is important, but there are other effects, especially with statins, where it helps to decrease inflammation and plaque rupture, that we don't just look specifically only at the number.
00:00:46 Narrator
Welcome to Medication Talk, an official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources.
00:00:55 Narrator
Proud to be celebrating 40 years of unbiased evidence and recommendations.
00:01:00 Narrator
On today’s episode, listen in as our expert panel discusses the latest recommendations for managing medications after heart attacks and other cardiac events.
00:01:09 Narrator
You’ll hear our panelists review which antiplatelets to use, the optimal blood pressure meds, and the role of statin and non-statin cholesterol meds.
00:01:18 Narrator
Our guests today are Dr. Danielle Blais from the Richard M. Ross Heart Hospital and The Ohio State University Wexner Medical Center and Dr. Joel C. Marrs from The University of Tennessee Health Science Center.
00:01:31 Narrator
You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board.
00:01:36 Narrator
Dr. Andrea Darby Stewart from The University of Arizona College of Medicine – Phoenix, and Dr. Craig Williams from the Oregon Health and Science University.
00:01:44 Narrator
This podcast is an excerpt from one of TRC’s monthly live CE webinars.
00:01:49 Narrator
Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.
00:02:00 CE Narrator
And now the CE information.
00:02:05 Narrator
This podcast offers Continuing Education credit for pharmacists, pharmacy technicians, physicians, and nurses.
00:02:12 Narrator
Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
00:02:22 Narrator
None of the speakers have anything to disclose.
00:02:27 Narrator
Now, let’s join TRC Editors, Dr. Sara Klockars and Dr. Stephen Small and start our discussion!
00:02:35 Steven Small
Anti-platelets are used to prevent clotting and major adverse cardiovascular events during and after ACS, but this also needs to be weighed with their increased bleeding risks as well.
00:02:46 Steven Small
So to jump in here on this topic with antiplatelets Craig, what factors play a role in which antiplatelet regiments are used after ACS?
00:02:59 Craig Williams
When we're getting those patients ready for discharge and or handing them off to our outpatient colleagues and kind of the near term post ACS setting that.
00:03:08 Craig Williams
I'd say the big complication these days is we've learned a lot about our patients who are on oral anticoagulants and we need to think differently about if they're on oral anticoagulants, going home or or on.
00:03:20 Craig Williams
It prior to the ACS.
00:03:21 Craig Williams
Or not, and that would have been a big kind of change in the guidelines. Speaking of brewing for a couple guidelines and ACH.
00:03:29 Craig Williams
Says Joel knows well the cardiology guidelines there. There's different groups writing different things, and there's guidelines for PCI and now guidelines for chronic coronary.
00:03:36 Craig Williams
These and but we kind of have a somewhat unified guideline now. So if we're receiving those patients and the kind of outpatient setting and they've just had an event, then the recommendations kind of range from astern by itself. Once you're truly stable to actually know and to platelets, if you have chronic stable disease and you're on a doac.
00:03:58 Craig Williams
But in setting the coordinate syndrome which you asked about. So if I have any cute coronary syndrome to some degree, it's dual antiplatelet for some duration of time and the considerations again are do I have an anticoagulant? And then what specifically what is my acute coronary syndrome? So was it a A STEMI and STEMI or a non MI event?
00:04:18 Craig Williams
But the big factors to consider are are is my patient on an anticoagulant and then what event do they have and what was done to them in the hospital? So because cabbage is managed a bit differently than PCI?
00:04:30 Danielle Blais
So I think first of all would be the basic counter indications and precautions for the medications would be the first thing to consider.
00:04:39 Danielle Blais
And then looking at patient specific factors that may go into the antiplatelet that we would choose specifically, are they able to afford it, their compliance with medications or adherence to medications and being able to take something once a day versus twice a day?
00:04:56 Danielle Blais
And then ultimately, other procedural factors such as what type of stent was put in, how many stents are also things that I would consider.
00:05:06 Danielle Blais
And then lastly, other concomitant medications that the patient would have to be on such as anticoagulants.
00:05:13 Steven Small
Great. And that kind of leads to this proverbial question with dual antiplatelet therapy, how long should they be continued after ECS? And also what factors influence that decision?
00:05:25 Danielle Blais
So as far as the duration of delay and platelet therapy, some of those things, things that you consider as far as which antiplatelet or P2Y12 inhibitor also would go in and I think be considered for the duration of dual antiplatelet therapy.
00:05:42 Danielle Blais
I know we'll talk about anticoagulation later on, but if they do have to be on anticoagulation in addition to antiplatelet therapy, that does play a very large factor into the duration of dual antiplatelet therapy and specifically getting down to one of the antiplatelet agents to minimize that bleeding risk.
00:06:01 Danielle Blais
And then also procedural factors such as. Was it a left green stent? Do they have multiple stents, overlapping stents, all of those things may go into a longer duration of dual antiplatelet therapy.
00:06:16 Danielle Blais
And fortunately for us, I think people are more looking into specific scores or ways for us to determine the duration of dual antiplatelet therapy. I think that's a field that we have a lot more to learn about, but sometimes us kind of just picking out of the air the duration and doing it with therapy versus having some very objective ways of looking at it.
00:06:37 Danielle Blais
It can be more helpful.
00:06:40 Craig Williams
Just always add briefly, Steve, that when you know cause in teaching internal medicine, residents and feminist residents and medical students have to think about this in their future patients. It's kind of as little as a month for dual into play, depending setting and generally not much longer than a year. So it's kind of between a month and a year. And as Danielle said, occasionally for longer term if.
00:06:59 Craig Williams
They're really stable.
00:07:02 Joel C. Marrs
I think there's definitely some provider specific approaches, but with the guidelines being updated recently, I would say there's been probably even before that update in the guidelines. In my practice, a shorter duration of dual antiplatelet therapy, especially in those that are considered high bleeding risk or have a history of bleeding.
00:07:23 Joel C. Marrs
And so I would say we kind of backing off to sapped or single anti plate that there be a little bit quicker than we once used to, but there still are those individuals that will continue on for that full year out. I would say I don't tend to see a ton of patients, they're on kind of that dapps beyond that 12 month window as we used to see some of those in the past.
00:07:47 Steven Small
Great insight there. What dose of aspirin do you recommend post ACS?
00:07:54 Joel C. Marrs
So the bulk of the data kind of aligns with low dose aspirin at that 81 milligram dose for kind of chronic maintenance therapy post ACS acknowledging that they're going to get a loading dose during that acute presentation. But chronic use would be that 81 milligram.
00:08:12 Steven Small
Great, now that we've talked about dual life therapy and single antiplatelet therapy, let's add another dimension, triple antiplatelet therapy. So when should patients be on that and how long should that be used for?
00:08:27 Joel C. Marrs
This situation arises when patients have an indication for anticoagulation in addition to their adapt and so commonly could be atrial fibrillation or history of clotting in the past. So they could be coming in the door on anticoagulants or it could be diagnosed and started during the hospitalization.
00:08:44 Joel C. Marrs
While the latest update and recommendations from the 2025 guidelines have discussed and and trying to back off on that adapt piece as quickly as possible, and so they actually have a recommendation if patients aren't going to need to be on anticoagulants in addition to their adapt that backing off.
00:09:05 Joel C. Marrs
Within that first month, some data supports even after a week of ADAPT, but I would say more consistently in practice would be a month of triple therapy and then backing off to a doac plus.
00:09:17 Joel C. Marrs
A P2Y12 inhibitor. And then once they're out of that thrombosis risk window with antiplatelets then going back to the duac alone based on their indication.
00:09:29 Steven Small
Thank you, Joel. And to clarify the doac anticoagulants we're talking about here specifically our Pixel ban, dabigatran, edoxaban and rivaroxaban I.
00:09:39 Steven Small
Really like that?
00:09:40 Steven Small
Afib example and it shows that these meds play an important role for many of our patients with additional indications.
00:09:47 Steven Small
Now, over to you, Sarah.
00:09:50 Sara Klockars
Thanks, Steve. Now let's move along to talk about blood pressure management and the role of ACE inhibitors or Arbs post ACS.
00:09:59 Sara Klockars
And Andrea, can you start us off what blood pressure goal do you aim for with patients who've just had an MRI or have unstable angina?
00:10:08 Andrea Darby Stewart
So typically the blood pressure goals that we're looking for are going to be generally in the less than 130 / 80 range, although I understand that the American.
00:10:18 Andrea Darby Stewart
Cardiology still allows us to be in a target range of at least less than 140 / 90. We do know that if we drive blood pressures too low in the less than 100 to 110 range, then we can actually have increased adverse effects with appropriate shared decision making with patients. I generally try and have my patients.
00:10:37 Andrea Darby Stewart
Post MI and the less than 130 / 80 range.
00:10:42 Sara Klockars
Great. Thank you. Blood pressure control is key to lowering cardiovascular risk and both ACE inhibitors or Arbs and beta blockers are considered important components of secondary prevention after an MRI. So let's start with discussing the renin angiotensin aldosterone system inhibitors specifically.
00:11:03 Sara Klockars
Focusing in on ACE inhibitors or arms. So Joel, can you comment on which Med class is more effective and if there's a best ace or an arm to use?
00:11:14 Joel C. Marrs
Yeah, that's a great question that comes up frequently. I would say based on the literature and clinical trial data, when you compare Aces and Arbs, there's really not one that's better than the other. And even within the class because their class effects on the benefit of reducing Mace in these patients long term, there's really not necessarily a preferred agent.
00:11:35 Joel C. Marrs
I would say clinically, you're probably not going to be routinely using, say, ACE inhibitors that need to be dosed twice or three times a day versus once a day to help with medication and.
00:11:46 Joel C. Marrs
But overall, there's really not necessarily a preferred one of the biggest things is is making sure that patient can actually get the medication. And fortunately, because we have generically available Aces and Arbs, that usually is not an issue.
00:12:01 Sara Klockars
Excellent. Thank you. Danielle, would you want to chime in on that? Do you have anything to add?
00:12:07 Danielle Blais
The only other thing which I know this wasn't part of the question, but I think does come into this picture is use of a secure travelstart and also I typically tend to stick with either ACE inhibitor or a RB and I think 1 isn't necessarily be more effective than the other and I I don't really have a.
00:12:28 Danielle Blais
True preference for any one over the other other than maybe some of them might be dosed twice a day. So just looking at that versus the ones that we would dose daily.
00:12:40 Craig Williams
In the setting of hypertension and Daniel's right, if it's heart failure, have to think about some other things. But in hypertension, we're going to teaching to be in our first more for tolerability. So as Joel said, there's really not an efficacy difference. We have inexpensive Arbs now and they are better tolerate there is less Andrew Demon a bit less dry cough and it kind of makes a difference over hundreds or thousands of patients and healthcare system so.
00:13:02 Craig Williams
You don't see reason not to be leaning towards Arbs more for tolerability, not for effectiveness.
00:13:09 Sara Klockars
Excellent point. And then we've had a couple of questions from pharmacists saying their patients are on an ACE inhibitor with an ARB. Is that recommended?
00:13:19 Sara Klockars
Joel, would you want to tackle that one?
00:13:23 Joel C. Marrs
Sure. So really there's not a huge role for the combination therapy. There's really two subpopulations that there's actually any data that could support a potential benefit 1 is in heart failure with one clinical trial demonstrating that adding an ace to an ARB is an option. But I would say.
00:13:42 Joel C. Marrs
With the changing landscape and the use of.
00:13:44 Joel C. Marrs
Arnie's quicker and heart failure management with reduced ejection fraction. I would say that's really not necessarily an approach that's taken commonly. The other areas of someone actually has a gross protein area. There is some data to support further reduction and spilling protein with the combination, but really that's.
00:14:05 Joel C. Marrs
Not necessarily a a commonly seen thing and the reason for that is that there was 1 clinical trial on target that basically compared an ACE inhibitor to an arm in the.
00:14:14 Joel C. Marrs
Combination and there really was no difference in efficacy from major cardiovascular event standpoint, but there was higher toxicity. So you saw more hyperkalemia, you saw some more renal dysfunction associated with the combination therapy. And so in general management of hypertension, it's not necessarily a recommended.
00:14:34 Joel C. Marrs
Approach one or the other, but not both together.
00:14:39 Sara Klockars
Thank you. And I'm going to move this along to beta blockers.
00:14:44 Sara Klockars
So Danielle, would you want to comment on which beta blockers patients should start and when they should start them?
00:14:52 Danielle Blais
So first as far as which ones should be started, a lot of this can often be driven by the fact that patients with post ACS may also have heart failure. So we have our evidence based beta blockers that can be used for those patients. I would say most commonly carvedilol and metoprolol succinate or.
00:15:12 Danielle Blais
The extended release form movement, Toprol and possibly bisoprolol if they don't have heart failure. Often the next consideration would be is the patient. Someone that you're more trying to control their heart.
00:15:25 Danielle Blais
State which we would lean towards metoprolol succinate because of its activity at the beta one receptor versus someone that maybe needs some help with lowering their blood pressure as well as controlling their heart rate curvature well is one that we commonly would reach for. I think the next question that you had is when should we start a beta blocker?
00:15:46 Danielle Blais
I think this is a little bit of a loaded question now with some of the trials that have most recently been published with use of beta blockers in this patient population.
00:15:54 Danielle Blais
But kind of considering.
00:15:57 Danielle Blais
For arrhythmias, for example, then a bio blocker started.
00:16:01 Danielle Blais
Sooner if they can tolerate it would be best.
00:16:04 Danielle Blais
And then looking at patients who maybe don't have arrhythmias or heart rate is not a concern, but would maybe be more compromised by putting on a beta blocker, so elderly patients or patients with lower blood pressure without arrhythmias should be considered. So I think this is probably one of the areas in comparison to 20 years ago when I started.
00:16:26 Danielle Blais
Practicing that, there's kind of been maybe a little bit of a paradigm shift.
00:16:31 Sara Klockars
Joe, do you have any comments about when to start? And then I would also love your thoughts on how long patients should be on a beta blocker in light of the recent guidelines and more recent evidence.
00:16:44 Joel C. Marrs
Yeah. So I would say the same points in regards to starting it that Danielle brought up, I think the question of length of therapy has kind of evolved over the last number of years. And so the guidelines discuss, you know, treating out to evidence, to supporting out to at least three years post ACS. But as we've kind of seen with some more recent trial data.
00:17:05 Joel C. Marrs
Supporting that if someone doesn't have reduced ejection fraction heart failure and has preserved ejection fraction that there's not necessarily benefit extending out even beyond a year. And so you're starting to see some practice change and and some patients only being on a beta blocker for somewhere between one to three years.
00:17:25 Joel C. Marrs
Depending on their provider and that patient discussion.
00:17:31 Sara Klockars
Great. And then if somebody is stopping a beta blocker, how would you advise they do that safely?
00:17:39 Joel C. Marrs
So in general it should be tapered. Usually it's safe to taper a beta blocker or off over anywhere from kind of one to three weeks. Some of it's dose dependent of how high of dose the patients on and so maybe a longer taper if they're on a higher dose, but usually somewhere in that one to three-week window.
00:17:59 Sara Klockars
And then we did have a great subscriber question and I'd be curious to see, Andrea, you probably see these patients in your practice after the fact. If a patients having a low blood pressure on the ACE inhibitor and beta blocker, which Med should you lower or stop first? Does one Med class have more benefits than the other? So do you have any comments there on?
00:18:19 Sara Klockars
Your approach to managing these patients post ACS.
00:18:24 Andrea Darby Stewart
Yeah, I would say that the majority of my patients who aren't.
00:18:27 Andrea Darby Stewart
Tolerating their medications are generally not tolerating the lower heart rate with the beta blocker, and after discussion with them will generally choose to continue. An Acer and ARB and taper off of the beta blocker to see if they tolerate that well. Again, that goal of ensuring that we manage their blood pressure and keep them in that less than.
00:18:48 Andrea Darby Stewart
You know 130 to 140 / 80 to 90 range so that we can do good secondary prevention.
00:18:55 Sara Klockars
Excellent. Does anybody else have a different approach in this scenario?
00:18:59 Craig Williams
Now just add that it goes back to kind of knowing for sure what happened with your patients, ACS and how they were managed. If you want to really optimize it to Danielle and Joe's points, there's answer with Mckennitt from beta blocker. And if there is a scheming damage that was not able to be addressed reverse and there is some kind of time to find benefit of that beta blocker whereas you know the.
00:19:19 Craig Williams
Scenario. If there's no left ventricular dysfunction, that that's really kind of more questionable, fine for hypertension, but not really an intrinsic ACS drug, but a beta blocker can be depending on if there's residual ischemic damage, depending how the ECS was managed.
00:19:34 Sara Klockars
Thank you. So let's move along to lipid lowering meds. Joel, we'd love your thoughts on the latest approach to lipid management. Are we targeting certain LDL or specific doses? What's the latest approach with the latest guidelines?
00:19:51 Joel C. Marrs
Sure. So the full guidelines from CHA date back to 2018. There was an expert consensus decision pathway update.
00:19:58 Joel C. Marrs
Created in 2022 and that's where some of the more recent data kind of came out and is in alignment with the chronic coronary disease guidelines as well as ACS. Now as it relates to the terminology, currently they're still using terminology of thresholds instead of goals and the current landscape.
00:20:18 Joel C. Marrs
But that threshold actually in these very high risk ACS patients is now recommended at 50.
00:20:25 Joel C. Marrs
5 milligrams per deciliter, and so with that more aggressive goal that's also brought up that many of these patients are needing two and three lipid lowering agents to actually get to that aggressive target. Most of the patients that fit into the ACS bucket fit into that very high risk. So having an event, plus multiple risk factors.
00:20:48 Joel C. Marrs
We still do want to target that at least 50% reduction, which ties to utilizing high intensity statin doses with atorvastatin or rosuvastatin. But you do have some patients that fit into that high group that you could get away with a less aggressive threshold or target of of less than 70. But I would say most of these patients are going to fit into that.
00:21:10 Joel C. Marrs
More aggressive, less than 55 goal.
00:21:14 Sara Klockars
Thank you. Another question, what do you tell patients worried about their LDL being too low and is there an LDL that's too low and what's the evidence there?
00:21:26 Danielle Blais
Yes. So I think this is a question that we've often seen change over the last few years. So there was a point in the guidelines where if the LDL was.
00:21:37 Danielle Blais
Less than 40, we would cut the statin dose in half and then we kind of reversed course on that and really want to try and drive that LDL cholesterol as low as possible. So I do try and explain to my patients because they sometimes will see numbers in the 20s and 30s with their LDL that that number is important.
00:21:57 Danielle Blais
But there are other effects, especially with statins, where it helps to decrease inflammation.
00:22:03 Danielle Blais
And plaque rupture that we don't just look specifically only at the number, this is also an education point for providers when we're running cause a lot of the new interns and residents will see a low number like that and maybe want to knee jerk dial back therapy with the addition of the PCSK 9 and habitos as well as.
00:22:24 Danielle Blais
Some of the data where we were looking at high intensity statins and moderate intensity statins, we saw that there wasn't some of the safety concerns that maybe ones were thought to be had with those low LDL's. So just kind of emphasizing to them that we do want that number low to prevent future events.
00:22:45 Sara Klockars
Excellent. And Angel, you had alluded to, you know those high intensity statins being first choice post ACS and so question for you with the recent guidance. When should you start a high intensity statin alone versus a high intensity statin with the ezetimibe?
00:23:04 Sara Klockars
And then we have also had the question from a subscriber, is a moderate intensity statin plus is that, am I OK if the patient doesn't want to use a high dose or a high intensity statin, So what are your thoughts on you know, jumping to two meds after a patient has their first event?
00:23:21 Joel C. Marrs
That's an excellent question. It is addressed in the the new 2025 ACS guidelines. You know first line and still recommended as kind of the core approach is using a high intensity statin up front. They did give a lower level recommendation, I believe it to be recommendation that you could start with a statin plus as that.
00:23:40 Joel C. Marrs
Type some of the driver for that is a trial at the safely show that you could use some of statin as as that a maybe as a combination therapy within 10 days of an ACS event and showed further lowering versus a statin alone. But I would still say the strongest data is for that high intensity statin monotherapy.
00:24:01 Joel C. Marrs
Front I think you could justify in some patient populations depending on what that baseline LDL is. If you know that they're going to need more than a 50% reduction.
00:24:10 Joel C. Marrs
I think it's very reasonable to start the combination of of a a high intensity statin and is out of my.
00:24:16 Joel C. Marrs
Together with that approach, especially in those knowing that you're going to need to get to that threshold of less than 55. And so I think that's an option in some patients.
00:24:28 Sara Klockars
Great. And Danielle, what are you doing in?
00:24:30 Sara Klockars
Your practice with post ACS.
00:24:34 Danielle Blais
Yeah. I think Joel hit the highlights. So we do try to start with a high intensity.
00:24:39 Danielle Blais
Statin but if there's a patient that needs a much bigger lowering of their LDL, we tend to use high intensity or moderate intensity statin pluses that Amit just because by doubling the dose of statin, you often don't get as much of an LDL lowering as you would with acetamide. And if there's any hesitancy in the patient.
00:24:59 Danielle Blais
Taking a high intensity stat in their previous intolerance, I'd rather do that than risk the patient not taking it.
00:25:06 Danielle Blais
We've been a lot more aggressive, especially when we have patients that have extremely high LDL's at trying to get them set up with a PCSK 9 inhibitor at discharge or with close follow up with a pharmacy clinic to make sure that those get started.
00:25:24 Sara Klockars
When you're starting those, are you starting those alone, or are you adding those on to the high intensity statin and instead of my?
00:25:33 Danielle Blais
Typically if we send them out and they're not on the PCSK 9 inhibitor at discharge, we'll do a statin. Pluses out of my and then with the hopes of getting that PCSK 9 inhibitor started, especially if there's somebody that has an extremely high LDL, if there's someone that we can't think that we can get the PCSK 9 inhibitors.
00:25:55 Danielle Blais
Like, no, they have it in hand when they go. Plus this, that and we may forego the acetamide, it just depends on the patient, the number of medications they're on. And if we think.
00:26:05 Danielle Blais
One last occasion is really going to make a difference as far as their ability to kind of keep up with the regimen that we're sending them out on. We may may or may not do that, but if there's any question about, you know, coverage of the PCSK 9 inhibitor or starting it, then we typically will use as that a minute and then maybe dial back later on down the road.
00:26:25 Sara Klockars
Great, thank you. So now I'll hand the reins back.
00:26:29 Sara Klockars
Over to you, Steve.
00:26:31 Steven Small
Thanks, Sarah. And let's move over to anti anginal meds.
00:26:35 Steven Small
Who should get anti anginal meds post ACS? Is it a select group of patients?
00:26:41 Joel C. Marrs
So it's going to be related to the kind of patients presentation and their history. So if this patients has a history of angina prior to their ACS event, then those are people that should be on antianginal medications. The fortunate thing is that most of these patients are are already going to be initiated on a beta blocker with their acute management treatment.
00:27:03 Joel C. Marrs
And so already going to have that on board. But any history, they should have a quick acting sublingual Nitro.
00:27:09 Joel C. Marrs
Cluster and available to them as well, just so that they have that. If they do need to treat angina symptoms moving forward and then over time then assessing are they still having angina post ACS event and if so maximizing their other therapies that could potentially lower the risk of having kind of chronic angina go on.
00:27:32 Steven Small
Great. And Danielle, are certain nitroglycerin dosage forms more effective than others that we should be leaning towards for these patients?
00:27:41 Danielle Blais
So I think in order to answer that question first is knowing whether you're talking about the acute management, so sublingual nitroglycerin or some patients will prefer the nitroglycerin spray versus if you're trying to provide chronic anginal coverage. And so that.
00:28:02 Danielle Blais
Really often depends on the patient preference and tolerability.
00:28:06 Danielle Blais
Some patients may prefer a long acting nitrate. I've had other patients where depending on when their angina occurs, if they're not responsive to long aftering nitrate may do better with a nitroglycerin patch, and there are some patients where we've had to use, albeit maybe not.
00:28:26 Danielle Blais
As Commons, different combinations of the long acting nitroglycerin and patch obviously not at the same time, but at different points during the day. So I really think the effectiveness often depends on how the patient responds and tolerates the different nitroglycerin forms.
00:28:45 Steven Small
And then, Joel, the question we sometimes get is, can you combine different anti anginal meds to kind of boost that effect if needed? Do you ever see that combination? Do you recommend that?
00:28:56 Joel C. Marrs
Yeah. So the chronic coronary guidelines as it relates to angina management chronically still recommends beta blockers as the first line therapy option there. And then combining agents, it lists options that you could use a.
00:29:11 Joel C. Marrs
The dihydropyridine calcium channel blocker, in addition to a beta blocker or potentially a long acting nitrate products, could be used safely together. There is some data to support all three of those can be used safely together as well. What we generally try to avoid and this is based on the patients response from a heart rate standpoint with the beta.
00:29:32 Joel C. Marrs
Walker is generally are not using the combination of a non dihydropyridine with a beta blocker, even though that and some rare instances does come up in regards to lowering up patients heart rate. But most of the time.
00:29:45 Joel C. Marrs
It's if you're going to combine a calcium channel blocker, you're going to use a dihydropyridine with a beta.
00:29:52 Steven Small
And Andrea, what are some counseling pearls for patients getting? Nitroglycerin tabs, for example. I know there could be some storage things to think about, but also we sometimes get the question can you get addicted to nitroglycerin or become dependent on it as needed? What's your take on that?
00:30:11 Andrea Darby Stewart
Sure. And I have many of my patients walking around with their nitroglycerin tablets, conveniently tucked in their shirt pocket or stored in their car, or places where they probably shouldn't be. So really trying to emphasize that, gosh, you should really try and keep the table.
00:30:25 Andrea Darby Stewart
In a temperature controlled environment and not let them get to body temperature or above in the setting that I work in is important. And then you know, people perceive pain and medications that take away pain is something that they can become addicted to, so really helping them understand what this medicine is supposed to do for them in the event that they do have.
00:30:45 Andrea Darby Stewart
Original symptoms and that they can't become addicted to it and the manner in which they have heard other medications like opioids, are addictive.
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