NURS 504 Week 6 Acute Coronary Syndrome Case Study Analysis Example

Acute Coronary Syndrome Case Study Analysis: Building the Discharge Regimen for a Retired Wrestling Coach After a Stent for NSTEMI

Case Summary

The patient is a 63-year-old retired high school wrestling coach admitted with chest pressure that began while shoveling snow. The electrocardiogram showed ST depression, troponin rose above the reference limit, and coronary angiography found a 90% stenosis in the proximal left anterior descending artery, treated with a drug-eluting stent. The echocardiogram shows a left ventricular ejection fraction of 50%. Before admission the patient took amlodipine 5 mg daily for hypertension and no other drugs. LDL cholesterol is 142 mg/dL, the eGFR is 75, and there is no history of bleeding, stroke or liver disease. The patient quit smoking five years ago and wants to return to coaching youth wrestling as a volunteer.

Assessment

The diagnosis is an NSTEMI, managed with angiography and a single drug-eluting stent, in a patient with preserved ejection fraction, hypertension and hyperlipidemia. The priorities at discharge are preventing stent thrombosis and recurrent events, lowering LDL cholesterol substantially, controlling blood pressure and returning the patient safely to activity. In the first year after a stent, the most dangerous medication error is not a wrong dose but a missed antiplatelet pill.

Pharmacologic Plan

Dual Antiplatelet Therapy

The patient should take aspirin 81 mg daily indefinitely and ticagrelor 90 mg twice daily for 12 months, the default duration of dual antiplatelet therapy after acute coronary syndrome in the 2025 guideline for patients without high bleeding risk (Rao et al., 2025). Aspirin irreversibly inhibits cyclooxygenase-1 and thromboxane A2 production in platelets, while ticagrelor reversibly blocks the P2Y12 adenosine diphosphate receptor (Burchum & Rosenthal, 2019). In the PLATO trial of 18,624 patients with acute coronary syndromes, ticagrelor reduced the combined rate of vascular death, myocardial infarction and stroke at 12 months compared with clopidogrel, without an increase in overall major bleeding, though non-procedural bleeding was higher (Wallentin et al., 2009). Aspirin must stay at 100 mg or less with ticagrelor, because higher aspirin doses reduced ticagrelor's benefit. Prasugrel would be an alternative, but ticagrelor is chosen here because the patient's age and weight raise no concern and twice-daily dosing fits the patient's routine.

High-Intensity Statin

Atorvastatin 80 mg daily should start before discharge. Statins inhibit HMG-CoA reductase, lowering LDL cholesterol and stabilizing plaque, and high intensity is recommended after acute coronary syndrome. The 2025 guideline sets an LDL goal below 70 mg/dL and supports adding ezetimibe or other non-statin therapy if the goal is not met (Rao et al., 2025). A fasting lipid panel in four to eight weeks will show whether the patient has reached it.

ACE Inhibitor

Because of hypertension, an ACE inhibitor such as lisinopril 10 mg daily should be added, with amlodipine continued if blood pressure requires it. ACE inhibitors reduce afterload and adverse remodeling after infarction and are recommended when hypertension, diabetes, kidney disease or reduced ejection fraction is present.

The Beta-Blocker Question

Long-term beta-blockers after myocardial infarction were once routine for every patient, but the evidence has changed. In the REDUCE-AMI trial of 5,020 patients with myocardial infarction and preserved ejection fraction, long-term beta-blocker treatment did not reduce death or recurrent myocardial infarction compared with no beta-blocker (Yndigegn et al., 2024). With an ejection fraction of 50% and no arrhythmia, a beta-blocker is optional here; it could be used if the patient has angina or a high resting heart rate, but it is not required for survival. Amlodipine already provides blood pressure and antianginal benefit.

Sublingual Nitroglycerin

Nitroglycerin 0.4 mg sublingually as needed relieves angina by dilating veins and coronary arteries. The patient should take one tablet for chest pain, call 911 if the pain is not better five minutes after the first dose, and avoid phosphodiesterase-5 inhibitors for erectile dysfunction within the stated time windows, because the combination can cause severe hypotension (Wells et al., 2018).

Cardiac Rehabilitation and Lifestyle

Referral to a cardiac rehabilitation program before discharge is a strong recommendation after acute coronary syndrome and improves survival and quality of life (Rao et al., 2025). For this patient, rehabilitation also provides supervised exercise testing before returning to wrestling practice. A heart-healthy diet, weight management and continued abstinence from tobacco complete the plan, and a flu shot every autumn, since respiratory infection raises short-term cardiac risk.

Drugs Considered and Not Chosen

A critique partner may ask about several alternatives. Clopidogrel is less potent and has variable response because of genetic differences in its activation, so it is reserved for patients who cannot take ticagrelor or prasugrel or who need an oral anticoagulant as well. An SGLT2 inhibitor or mineralocorticoid antagonist is not indicated without heart failure, diabetes or reduced ejection fraction. A proton pump inhibitor is worth considering for patients on dual antiplatelet therapy who have a history of ulcers or other bleeding risk factors; this patient has none, but the question should be revisited if dyspepsia develops. Starting each of these without an indication would add cost, pills and side effects without benefit.

Follow-Up Timeline

The first visit within two weeks should review symptoms, bleeding, ticagrelor breathlessness, blood pressure, potassium and creatinine. At four to eight weeks, the lipid panel decides whether ezetimibe is needed. Cardiac rehabilitation typically begins within a few weeks and runs for about 12 weeks. At 12 months, the team will decide whether to stop ticagrelor and continue aspirin alone, which is the usual step for patients who have had no events or bleeding.

Monitoring and Adverse Effects

Ticagrelor commonly causes a sensation of breathlessness that is usually mild and fades; patients may stop the drug because of it, so they must be warned to call rather than stop. Bleeding is the main risk of dual antiplatelet therapy, and the patient should report black stools, blood in the urine or vomit, or unusual bruising. Ticagrelor levels rise with strong CYP3A4 inhibitors such as clarithromycin and some antifungals, which should be avoided. Statins can cause muscle aches and rarely liver enzyme elevation; most aches are not caused by the statin, so the drug should not be stopped without discussing it with the team. Potassium and creatinine should be checked one to two weeks after starting lisinopril, and cough or facial swelling should be reported. The first follow-up visit should occur within two weeks of discharge, and the nurse should confirm at that visit that both antiplatelet prescriptions were filled and that the patient has enough of each to avoid a gap at refill time.

Patient Education

The patient should be able to explain the purpose of each drug, why ticagrelor must not be stopped without the cardiology team's approval, how to use nitroglycerin, which bleeding signs need attention, and when to call 911. Because the patient is used to pushing through physical strain as a coach, it is worth stressing that chest pain during exertion is a reason to stop, not to keep going.

Teaching Points for Nursing Students

This case gives nursing students three lessons. Antiplatelet adherence after a stent is a safety issue as serious as any high-alert drug, and every discharge teaching session should treat it that way. Defaults in cardiology change, as the beta-blocker evidence shows, so practice must follow current trials rather than habit. And cardiac rehabilitation is a therapy with survival benefit, which nurses can promote by making the referral before the patient leaves.

References

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care (10th ed.). Elsevier.

Rao, S. V., O'Donoghue, M. L., Ruel, M., Rab, T., Tamis-Holland, J. E., Alexander, J. H., Baber, U., Baker, H., Cohen, M. G., Cruz-Ruiz, M., Davis, L. L., de Lemos, J. A., DeWald, T. A., Elgendy, I. Y., Feldman, D. N., Goyal, A., Isiadinso, I., Menon, V., Morrow, D. A., . . . Williams, M. S. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 151(13). https://doi.org/10.1161/CIR.0000000000001309

Wallentin, L., Becker, R. C., Budaj, A., Cannon, C. P., Emanuelsson, H., Held, C., Horrow, J., Husted, S., James, S., Katus, H., Mahaffey, K. W., Scirica, B. M., Skene, A., Steg, P. G., Storey, R. F., & Harrington, R. A. (2009). Ticagrelor versus clopidogrel in patients with acute coronary syndromes. The New England Journal of Medicine, 361(11), 1045-1057. https://doi.org/10.1056/NEJMoa0904327

Wells, B. G., DiPiro, J. T., Schwinghammer, T. L., & DiPiro, C. V. (2018). Pharmacotherapy handbook (10th ed.). McGraw-Hill Education.

Yndigegn, T., Lindahl, B., Mars, K., Alfredsson, J., Benatar, J., Brandin, L., Erlinge, D., Hallen, O., Held, C., Hjalmarsson, P., Johansson, P., Karlström, P., Kellerth, T., Marandi, T., Ravn-Fischer, A., Sundström, J., Östlund, O., Hofmann, R., & Jernberg, T. (2024). Beta-blockers after myocardial infarction and preserved ejection fraction. The New England Journal of Medicine, 390(15), 1372-1381. https://doi.org/10.1056/NEJMoa2401479