Assess LVEF, residual ischaemia, completeness of revascularisation.
Check risk markers: LDL-C, HDL-C, triglycerides, fasting glucose, renal function.
⚠️ LDL-C should be measured on admission (levels may fall post-ACS).

💊 Antithrombotic Therapy

Dual Antiplatelet Therapy (DAPT): Aspirin (75–100 mg OD) + P2Y12 inhibitor (e.g. ticagrelor, prasugrel, or clopidogrel). Continue ≥12 months if low bleeding risk.
Triple Therapy: For AF / prosthetic valves: triple therapy ≤1 week, then anticoagulant + single antiplatelet up to 12 months.
After 12 months → usually aspirin monotherapy.

🩸 Anticoagulation (selected cases)

AF with CHA₂DS₂-VASc ≥2 → anticoagulant ± antiplatelet (guided by bleeding risk).
LV thrombus post-MI → LMWH bridging to warfarin (or DOAC if appropriate).
Prolonged immobility post-MI → LMWH prophylaxis.

🧬 Lipid Management

LDL-C target: <1.4 mmol/L and ≥50% reduction from baseline.
Statins: High-dose (Atorvastatin 80 mg nocte). Proven mortality reduction post-ACS.
Consider ezetimibe or PCSK9 inhibitor if LDL-C target not achieved.

💊 Key Medications

Beta-blockers: Indicated if LVEF ≤40% (Class I, LOE A).
ACE inhibitors: Ramipril 2.5 mg → titrate to 10 mg daily. If intolerant → ARB (valsartan/losartan).
Aldosterone antagonist: Eplerenone 25 mg OD in STEMI + LVEF ≤40% with DM or HF symptoms.
Polypill strategy: Fixed-dose combinations may improve adherence.

🚭 Lifestyle & Risk Modification

Smoking cessation: Offer NRT, varenicline/bupropion if appropriate. Refer to NHS stop-smoking services.
Diet: Mediterranean diet (fish, nuts, 5-a-day, low sat fat, ↑ soluble fibre).
Exercise: Mobilise early; target 150 min/week moderate intensity. Enrol in cardiac rehabilitation.

📊 Quick Summary Table

Drug / Strategy	Indication	Notes
🩸 DAPT	All ACS patients unless contraindicated	Aspirin + P2Y12 inhibitor ≥12 months
💊 Anticoagulation	AF, LV thrombus, prosthetic valves	Triple ≤1 week → OAC + SAPT
🧬 Statins	All post-ACS	Atorvastatin 80 mg nocte; LDL-C <1.4 mmol/L
❤️ Beta-blockers	LVEF ≤40%	Reduce mortality & arrhythmia
💊 ACEI/ARB	LVEF <40%, DM, HTN, CKD	Titrate to max tolerated dose
💊 Eplerenone	Post-STEMI, LVEF ≤40% + DM/HF	Monitor K⁺ and renal function
🚭 Lifestyle	All patients	Stop smoking, Mediterranean diet, cardiac rehab

💡 Exam tip: Post-ACS secondary prevention is about “Drugs + Lifestyle + Rehab”. Always mention cardiac rehabilitation and HCC surveillance in cirrhotics.

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Secondary prevention Post Acute Coronary Syndrome

🫀 Secondary Prevention Post-ACS / IHD

📋 Prior to Discharge – Risk Assessment