Ticagrelor or prasugrel is recommended in preference to clopidogrel

Dual antiplatelet therapy is recommended in ACS patients. Ticagrelor or prasugrel is recommended in preference to clopidogrel in NSTE-ACS and STEMI patients undergoing PCI. In patients with NSTE-ACS planned for an invasive strategy with timing of angiography to be >24 hours, upstream treatment with clopidogrel or ticagrelor may be considered to reduce MACE.

Dual antiplatelet therapy with aspirin and an oral P2Y12 inhibitor is indicated for at least 12 months as the default strategy in patients with ACS who are not at high bleeding risk. Several strategies are available to reduce bleeding risk in patients with ACS who have undergone PCI: a) in patients at risk for gastrointestinal bleeding, a proton pump inhibitor is recommended; b) in patients who have tolerated DAPT with ticagrelor, transition to ticagrelor monotherapy is recommended ≥ 1 month post PCI; c) in patients who require long-term anticoagulation, aspirin discontinuation is recommended 1-4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel).

High-intensity statin therapy is recommended for all ACS patients with the option to initiate concurrent ezetimibe. A non-statin lipid lowering agent (ezetimibe, evolocumab, alirocumab, inclisiran, bempedoic acid) is recommended for patients already on maximally tolerated statin who have an LDL-C ≥70 mg/dl (1.8 mmol/L). It is reasonable in this high-risk population to further intensify lipid-lowering therapy if LDL-C 55-<70mg/dl (1.4-<1.8 mmol/L) and already on maximally tolerated statin.

After discharge, focus on secondary prevention is fundamental: a fasting lipid panel is recommended 4 to 8 weeks after initiation or dose adjustment of lipid-lowering therapy and referral to cardiac rehabilitation