3 days ago
ACS Guidance Makes Hospitalists' Cardiac Decisions Easier
Hospitalist Arti Tewari, MD, no longer has to second-guess some of her decisions about the best treatment for managing patients with acute coronary syndrome (ACS). New ACS clinical practice guidelines she refers to as 'groundbreaking' help her more confidently care for her cardiac patients at UChicago Medicine to improve their health and safety, she said.
'There have been times previously where I have weighed the risks and benefits of dual antiplatelet therapy, specifically not knowing if a patient would need open heart surgery or bypass surgery and not wanting to delay that surgery by giving them antiplatelet agents,' said Tewari, assistant professor of medicine at the University of Chicago in Chicago.
Since hospitalists are among the first clinicians to care for patients with ACS when they are admitted into the hospital, Medscape Medical News sought to learn how the specialty physicians apply the new guidelines in their practice.
The directive to use more antiplatelet therapy was one of the biggest changes Tewari noted in the new guidelines released earlier this year by the American College of Cardiology and the American Heart Association. It was the first update in the guidelines in more than a decade.
ACS continues to be a leading cause of morbidity and mortality worldwide, with an estimated 1.2 million individuals in the US hospitalized with the group of acute cardiovascular conditions defined by sudden reduced blood flow to the heart muscles, according to the AHA's 2024 data.
Arti Tewari, MD
Symptoms include chest pain, shortness of breath, and dizziness. Associated conditions include unstable angina and myocardial infarction, or a heart attack.
Tewari said patients with ACS typically come to the hospital complaining of chest pain. Hospitalists often are the first to manage their care, deciding if they are experiencing a cardiac, muscular, or another issue such as gastrointestinal reflex.
If hospitalists suspect a cardiac condition, they may consider whether the patient needs intervention such as a stent for a potential lesion in one of their coronary arteries. In that case, the hospitalist would administer antiplatelet agents as recommended in the guidelines while the patient is being stabilized for that procedure.
Another change Tewari noticed in the guidance was more careful optimization of lipid-lowering agents. 'We used to use statins and to really kind of go based off of a cumulative risk score for our patients, but with these new guidelines there's really a push for non-statin lipid-lowering agents, and that is definitely a change in my practice that I think is going to benefit the patients greatly.'
Focus Areas for Hospitalists
The committee that drafted the new guidelines kept hospitalists in mind along with other clinicians who might provide care for patients with ACS during their treatment path, said Michelle O'Donoghue, MD, MPH, vice chair of the ACS guideline writing committee.
Hospitalists tend to see such patients after they are stabilized following coronary revascularization or readmitted after a recent ACS event, said O'Donoghue, a cardiologist at Brigham and Women's Hospital and an associate professor at Harvard Medical School, Boston.
Like other clinicians following the new guidelines, hospitalists should become aware of the new recommendations for using lipid-lowering therapy and the selection and duration of dual antiplatelet therapy (DAPT), O'Donoghue told Medscape Medical News, for which she frequently posts cardiology commentaries. She also serves on Medscape's cardiology advisory board.
O'Donoghue summed up some of the key points of the new guidelines for hospitalists and other clinicians, especially early after an ACS event.
'The new ACS guidelines want to target an LDL [low-density lipoprotein] cholesterol that is < 55 mg/dL, so, by and large, all patients should be on a high-potency statin, barring any contraindication, and if they're already on a high-potency statin, then the hospitalist should be initiating a non-statin lipid-lowering therapy.'
She cited several non-statin lipid-lowering therapies that can be considered, including proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, and bempedoic acid, that can help patients achieve their LDL cholesterol goal.
'But if they're not at goal and they're already on a high-potency statin, then really the hospitalist should be initiating non-statin therapies before hospital discharge and then also making sure that that patient is scheduled to have their lipid panel rechecked in another 4-8 weeks to make sure as an outpatient that they are, in fact, achieving that goal.'
Hospitalists should also focus on management of antiplatelet therapy, O'Donoghue said. 'By and large all patients who undergo placement of a stent will be on dual antiplatelet therapy including aspirin and a P2Y12 inhibitor for some period of time after that stent is placed, but the duration is somewhat variable,' she explained.
'The important area for the hospitalist to know is that if the patient requires the addition of an anticoagulant, then the aspirin should be discontinued 1-4 weeks after PCI [percutaneous coronary intervention] for a patient who does not require an anticoagulant while the P2Y12 inhibitor is continued.'
The guidelines now offer more flexibility during follow-up for the possibility of discontinuing DAPT earlier, O'Donoghue said. 'Traditionally, shorter duration of DAPT has meant stopping the P2Y12 inhibitor. However, the guidelines now have a class 1 recommendation to endorse the discontinuation of aspirin after 1-3 months for patients discharged on aspirin and ticagrelor to reduce risk of bleeding.'
She added that prasugrel and ticagrelor are both preferred over clopidogrel in the absence of a contraindication. 'But we recognize for the hospitalist, who might be caring for a patient early in the course of their ACS, that there may be barriers such as cost that prevent them from getting those more potent antiplatelet therapies,' O'Donoghue said.
'If there is a need to switch between therapies, the hospitalist should make sure that they are consulting the pharmacist to best understand how to do that.'
Hospitalists should also refer the patient to cardiac rehab if they have been recently diagnosed with an ACS, she said. 'There's been a clear benefit that has been shown for patients who participate in those types of programs.'
The guidelines even offer an alternative for a patient who can't attend in person — virtual cardiac rehab programs, she said.
Patients with ACS also should have an annual flu shot because the flu puts considerable stress on a recent patient with the heart condition, O'Donoghue said.
Practical Applications
Community-based hospitalist Jeff S. Shapiro, MD, believes the new guidelines offer 'a more nuanced approach to treatment of ACS with a continued emphasis on DAPT and aggressive lipid-lowering treatment, including clearer recommendations on adding non-statin therapy to patients who have either reached maximal doses of statins or in which statins are contraindicated.'
The guidelines on blood transfusion also 'feel more aggressive than what we are currently using,' said Shapiro, regional medical director of the Southern California Hospitalist Network, Orange, and chief of staff, elect, of Emanate Health Foothill Presbyterian Hospital in Glendora, California.
Jeff S. Shapiro, MD
'Recommendations such as microaxial flow pumps are less helpful for community-based physicians, as it will take time for that type of technology to reach our hospitals, although I used to say the same thing regarding stroke neuro-intervention, which we now do regularly at one of our hospitals.'
In general, Shapiro believes the new guidelines help community-based hospitalists discharge patients back to their primary care physicians on 'optimal medical therapy similar to what we are doing with goal-directed medical therapy' for congestive heart failure.
Bleeding Risks
For academic hospitalist Farzana Hoque, MD, the updates on DAPT, particularly the individualized step-down approach for high bleeding risk patients and lipid management, are especially valuable for patient care, she told Medscape Medical News .
The guidelines recommend at least 1 year of DAPT for patients with ACS who are not at high risk for bleeding to reduce major adverse cardiovascular events (MACE), said Hoque, associate professor of medicine at Saint Louis University in St. Louis.
Farzana Hoque, MD
She noted the guidelines' preference for ticagrelor or prasugrel over clopidogrel in patients with ST-segment elevation myocardial infarction — a more serious type of heart attack — managed with the nonsurgical PCI to reduce stent thrombosis and MACE.
'The updated recommendation favors clopidogrel over ticagrelor or prasugrel to minimize bleeding risk in patients requiring oral anticoagulation,' said Hoque, who also teaches the new recommendations to her medical students and residents.
She added that the old guidelines needed to be updated to reflect new evidence, evolving clinical practices, and advances in technology.
Care for High-Risk Patients
Hoque said she regularly consults such guidelines in her practice at the academic medical center, which cares for high-risk patients with diverse clinical and social needs from an underserved community.
Many of Hoque's patients are elderly with an increased tendency to bleed. So they will benefit from the update for patients with ACS who require anticoagulation.
When it comes to bleeding risk, Tewari said hospitalists also have to balance the risk for cardiac ischemia, reduced blood flow to the heart muscle because of blocked arteries.
'Every day we have patients who come in [the hospital] who make it successfully to a cardiac catheterization to unblock a heart vessel because of these guidelines,' she said.
She's gained confidence giving DAPT up front because the new guidelines suggest administering a large dose of it and then holding one of the platelet agents for 24 hours prior to a surgery, rather than 5 days.
While hospitalists are expected to stay informed of changing guidelines, Tewari admits there's a learning curve associated with them. 'Certainly, it's a pretty significant change than what I learned in my training,' she said, adding that her practice is teaching its staff and residents to provide the updated standard of care.
'The guidelines are definitely helpful for us to refer back to because we can't possibly know all of this off the top of our head.'
